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Answer the question based on the following context: To evaluate physicians' readiness to care for patients enrolled in consumer-directed health plans (CDHPs), which change the nature of cost sharing and medical decision making in primary care. Mailed cross-sectional survey of 1500 nationally representative primary care physicians. Physicians' knowledge of CDHP benefit design, readiness to advise patients about financial issues, and views regarding the role of quality-of-care information in patient decision making were assessed. Results were analyzed using descriptive statistics and multivariate models. Five hundred twenty-eight of 1076 eligible physicians (49%) responded to the survey. Forty percent of physicians had CDHP enrollees in their practices. Forty-three percent of physicians reported low knowledge of CDHP cost sharing, and approximately one-third reported low knowledge of how medical savings accounts function. Overall, physicians with CDHP enrollees in their practices had higher knowledge than physicians without these patients; however, 1 in 4 of these providers reported low knowledge of CDHP cost sharing. More than two-thirds of all physicians were ready to advise patients on the costs of office visits, medications, and laboratory tests; approximately half or less were ready to advise on the costs of radiologic studies, specialist visits, and hospitalizations. Forty-eight percent were ready to discuss medical budgets with patients. Twenty-one percent of physicians thought that patients could trust quality-of-care information from government Web sites, and 8% thought that patients could trust quality-of-care information from insurance Web sites.

Question: Are primary care physicians ready to practice in a consumer-driven environment?

Many primary care physicians report low knowledge of CDHPs, limited readiness to advise patients on issues of cost and medical budgeting, and minimal trust in quality-of-care information.

Answer the question based on the following context: A health knowledge questionnaire was used investigating and assessing the health campaign. The health campaign comprised four components: (1) television, (2) local press, (3) local radio and (4) places of worship. The target population were Indian residents in Southall, Ealing aged 60+. The aim was to get people to go and have their eyes tested at their local optometric practice. Optometric practices within the borough of Ealing collected sight-test data for the study over 6 months before and after the advertising campaign. The repeat in-depth glaucoma knowledge questionnaire showed a significant increase in the number of people who had heard of glaucoma rising from 22% to 53%. Before intervention, most people had heard about glaucoma from their GP, friend or relative. After intervention, the majority (69%) had heard of glaucoma from the radio.

Question: Can a public health intervention improve awareness and health-seeking behaviour for glaucoma?

This study has shown a significant increase in awareness from using different kinds of media and has shown radio to be the most effective in our target community. Although the campaign has raised awareness, this study has not shown a change in health-seeking behaviour.

Answer the question based on the following context: Although circumcision is commonly believed to protect against urinary tract infection (UTI), it is not unusual in neonates in Israel, where almost all male infants are circumcised. The aim of the study was to evaluate the burden of neonatal UTI in Israel and its relationship to circumcision. Medical records of neonates (<or =2 months old) hospitalised with UTI were reviewed and demographic and clinical data were collected. The second part of the study consisting of a telephone survey to assess timing and details concerning the circumcision, included two groups: a study group consisting of parents of male infants, aged 8-30 days, hospitalised with UTI, and a control group consisting of healthy neonates. 162 neonates (108 males, 54 females) were hospitalised with UTI. Mean age at admission was significantly lower in males (27.5 vs 37.7 days, p = 0.0002). The incidence of UTI in males peaked at 2-4 weeks of age, that is, the period immediately following circumcision. In females, the incidence tended to rise with age. Accordingly, male predominance disappeared at 7 weeks and the male-to-female ratio reversed. In the second part of the study, 111 males (<or =1 month old) were included: 48 post-UTI and 63 as a control group. While evaluating the impact of circumcision technique, we found that UTI occurred in six of the 24 infants circumcised by a physician (25%), and in 42 of the 87 infants (48%) circumcised by a religious authority; the calculated odds ratio for contracting UTI was 2.8 (95% CI 1 to 9.4).

Question: Is ritual circumcision a risk factor for neonatal urinary tract infections?

There was a higher preponderance of UTI among male neonates. Its incidence peaked during the early post-circumcision period, as opposed to the age-related rise in females. UTI seems to occur more frequently after traditional circumcision than after physician-performed circumcision. We speculate that changes in the haemostasis technique or shortening the duration of the shaft wrapping might decrease the rate of infection after Jewish ritual circumcision.

Answer the question based on the following context: Results of experimental studies suggest that neuroplastic changes may occur during depressive episodes. These effects have not been confirmed in patients with depression, to our knowledge. To examine changes in the brains of patients with major depression vs those of healthy control subjects. Prospective longitudinal 3-year study. Inpatients with major depression were recruited from the Department of Psychiatry and Psychotherapy, Ludwig Maximilians University of Munich, Munich, Germany, and controls were recruited from the local community. The study included 38 patients with major depression and 30 healthy controls. High-resolution magnetic resonance imaging was performed at baseline and 3 years later. Voxel-based morphometric measurements were estimated from magnetic resonance images, and psychopathologic findings were assessed at baseline, weekly during the inpatient phase, and then after 1, 2, and 3 years. Compared with controls, patients showed significantly more decline in gray matter density of the hippocampus, anterior cingulum, left amygdala, and right dorsomedial prefrontal cortex. Patients who remitted during the 3-year period had less volume decline than nonremitted patients in the left hippocampus, left anterior cingulum, left dorsomedial prefrontal cortex, and bilaterally in the dorsolateral prefrontal cortex.

Question: Depression-related variation in brain morphology over 3 years: effects of stress?

This study supports findings from animal studies of neuroplastic stress-related processes that occur in the hippocampus, amygdala, dorsomedial prefrontal cortex, dorsolateral prefrontal cortex, and anterior cingulum during depressive episodes.

Answer the question based on the following context: Observed reductions in firearm suicides in Australia have been linked to the 1997 national firearms agreement (NFA) introduced following the 1996 Port Arthur massacre. The NFA placed strong access restrictions on firearms. To assess the impact of legislative restrictions on the incidence of firearm suicide in Queensland and explore alternative or contributory factors behind observed declines. The Queensland suicide register (QSR) provided detailed information on all male suicides in Queensland (1990-2004), with additional data for Australia (1968-2004) accessed from other official sources. Trends in suicide rates pre/post NFA, and in method selection, were assessed using negative binomial regressions. Changing method selection patterns were examined using a cohort analysis of 5 years of age classes for Australian males. The observed reduction in firearms suicides was initiated prior to the 1997 introduction of the NFA in Queensland and Australia, with a clear decline observed in Australian figures from 1988. No significant difference was found in the rate pre/post the introduction of the NFA in Queensland; however, a significant difference was found for Australian data, the quality of which is noticeably less satisfactory. A marked age-difference in method choice was observed through a cohort analysis demonstrating both time and age influences. Within sequential birth cohorts, rates of firearms suicides decreased in younger males but increased in hanging suicides; this trend was far less marked in older males.

Question: Controlling firearms use in Australia: has the 1996 gun law reform produced the decrease in rates of suicide with this method?

The implemented restrictions may not be responsible for the observed reductions in firearms suicide. Data suggest that a change in social and cultural attitudes could have contributed to the shift in method preference.

Answer the question based on the following context: The illness and injury severity of patients in emergency situations is normally rated by the National Advisory Committee for Aeronautics (NACA) score. Different issues seem to limit the validity of the NACA score, therefore, the aim of the present investigation was to analyse the association between rescue experience of pre-hospital emergency physicians and the estimated jeopardy of patients' vital functions using the NACA score. In this retrospective study, the emergency chart protocols of patients in a ground-based emergency system from 2004 to 2005 were evaluated concerning patients demographic, diagnosis, and related NACA score. Emergency physicians were divided into two groups according to their experience as pre-hospital emergency physicians (group 1: less than 3 years and group 2: 3 or more years). The patients in groups 1 and 2 were comparable concerning the mean age (58+/-24 years vs. 58+/-24 years) and the percentage of males (each 54%). The reasons for the emergency call in both groups were comparable with respect to disease, trauma, and the combination of both (both 77%, 18%, and 5%, resp.). A higher percentage of emergency physicians of group 1 estimated a lower illness and injury severity score in comparison to emergency physicians of group 2 with a longer working experience (NACA I-III: 56% vs. 48%; p<0.05). Accordingly, physicians in group 1 estimated a smaller percentage of patients to be in life-threatening situations (NACA IV-V: 33% vs. 40%; p<0.05). There were no significant differences in the NACA categories VI (2%) and VII (7%) between both groups.

Question: Is there an association between the rating of illness and injury severity and the experience of emergency medical physicians?

The results demonstrate that emergency physicians with less rescue experience rated the severity of illness or injury relatively lower in comparison to colleagues who had worked in the pre-hospital setting for many years.

Answer the question based on the following context: Latinas are the fastest growing racial ethnic group in the United States and have an incidence of breast cancer that is rising three times faster than that of non-Latino white women, yet their mammography use is lower than that of non-Latino women. We explored factors that predict satisfaction with health-care relationships and examined the effect of satisfaction with health-care relationships on mammography adherence in Latinas. We conducted a cross-sectional survey of 166 Latinas who were>or=40 years old. Women were recruited from Latino-serving clinics and a Latino health radio program. Mammography adherence was based on self-reported receipt of a mammogram within the past 2 years. The main independent variable was overall satisfaction with one's health-care relationship. Other variables included: self report of patient-provider communication, level of trust in providers, primary language, country of origin, discrimination experiences, and perceptions of racism. Forty-three percent of women reported very high satisfaction in their health-care relationships. Women with high trust in providers and those who did not experience discrimination were more satisfied with their health-care relationships compared to women with lower trust and who experienced discrimination (p<.01). Satisfaction with the health-care relationship was, in turn, significantly associated with mammography adherence (OR: 3.34, 95% CI: 1.47-7.58), controlling for other factors.

Question: Are health-care relationships important for mammography adherence in Latinas?

Understanding the factors that impact Latinas' mammography adherence may inform intervention strategies. Efforts to improve Latina's satisfaction with physicians by building trust may lead to increased use of necessary mammography.

Answer the question based on the following context: There have been no previous studies regarding the effect of volatile anesthetics on human rhinovirus (RV) infection in airway epithelial cells of patients with an upper respiratory infection (URI). We have therefore evaluated in vitro the effect of isoflurane on RV infection in airway epithelial cells. A549 cells and RV-infected A549 cells were treated with isoflurane for 2 or 4 h. Surface expression of intercellular adhesion molecule-1 (ICAM-1) was assessed by flow cytometry, and effects on the secretion of interleukin (IL)-6 and IL-8 were measured by ELISA. The effect on RV replication in the cells was determined by viral titer. Isoflurane treatment for 2 or 4 h had no significant effect on ICAM-1 expression and secretion of IL-6 and IL-8 in control cells. Isoflurane also had no significant additional effect on RV-induced ICAM-1 expression and secretion of IL-6 and IL-8. Viral titers were not significantly influenced by isoflurane.

Question: Does isoflurane enhance rhinovirus replication and virus-induced cytokine secretion in airway epithelial cells?

Isoflurane treatment showed no additional effects with RV on ICAM-1 expression, secretion of IL-6 and IL-8, and viral titer in A549 cells. These results suggest that isoflurane itself may not increase further RV infections, inflammations, and viral replication in patients with a viral URI.

Answer the question based on the following context: There is increasing evidence that there are gender-related differences in the pharmacodynamics of neuromuscular blocking drugs. However, it is not known whether gender influences the pharmacodynamics of a pre-curarizing dose. In the first part, we measured the neuromuscular blockade after administration of rocuronium 0.03 mg/kg (10% of ED(95)) after induction of anaesthesia in 20 patients (10 female and 10 male patients) by electromyography. In the second part, 40 female and 40 male patients were observed for signs and symptoms of muscle weakness 2.5 min after injection of rocuronium 0.03 mg/kg before loss of consciousness. Succinylcholine-associated post-operative myalgia (POM) was also assessed. Median twitch heights were comparable between the two groups: 95.5 (range: 85-97; female) vs. 96.0 (range: 85-99; male), (NS). Train-of-four ratios were 97.5 (range: 64-100; female) vs. 99.0 (range: 52-100; male) (NS). Signs and symptoms of muscle weakness were observed in 64 (80%) patients, but there were no gender-related differences. The incidence and severity of POM did not differ significantly between the study groups.

Question: Are women more sensitive to a pre-curarization dose of rocuronium than men?

Pre-curarization with rocuronium 0.03 mg/kg affected men and women equally. Nor was the incidence and the severity of muscle weakness affected by gender.

Answer the question based on the following context: We aimed to evaluate the changes in cardiovascular-related health care utilization (drug therapies, hospitalizations) and mortality for the diabetic population during a 9-year period in Saskatchewan, Canada. We identified annual diabetes prevalence rates for people aged>or=30 years between 1993 and 2001 from the administrative databases of Saskatchewan Health. Annual rates of evidence-based drug therapies (antihypertensives, ACE inhibitors, beta-blockers, calcium channel blockers, 3-hydroxy-3-metaglutaryl coenzyme A reductase inhibitors [statins]), hospitalizations for cerebrovascular and cardiac events, and all-cause mortality were estimated. Rates were direct age and sex standardized using the 2001 Canadian population, and trends over time were assessed using Joinpoint regression. From 1993 to 2001, diabetes prevalence increased 34% (4.7-6.5%, P<0.001) with the highest rates in men and those aged>or=65 years. The rate of increase in diabetes prevalence appeared to slow in those aged<65 years (P<0.01 for trend). Significant increased use of evidence-based drug therapies was observed (41% increase in antihypertensive agents, 97% increase in ACE inhibitors, 223% increase in statin therapies; all P<0.05 for trend). During this period, both cerebrovascular and cardiac-related hospitalizations declined by 36% (9.5 vs. 6.1 per 1,000) and 19% (38.0 vs. 30.6 per 1,000) (P<0.05 for trends), respectively, with similar reductions regardless of sex. No change in all-cause mortality was observed (17.7 vs. 17.8 deaths per 1,000; P>0.05).

Question: The darkening cloud of diabetes: do trends in cardiovascular risk management provide a silver lining?

During our period of study, there was an increase in the utilization of evidenced-based drug therapies in people with diabetes and reductions in cardiovascular-related hospitalizations. Despite this, we observed no change in all-cause mortality.

Answer the question based on the following context: A 48-year-old right handed gardener presented with a white discoloration and numbness of her left ring finger. She reported cutting her roses without protection gloves so repetitive scratchy lesions especially of her left hand occurred. On examination the pulse of the left radial artery was absent. Allen's test showed a dominant ulnar supply of the palmar arch. Duplex ultrasound demonstrated an occluded aneurysm of the distal portion of the left radial artery. Furthermore there were occlusions of the first and fourth digital artery on MR angiography probably due to distal emboli of the radial aneurysm. After exclusion of systemic disease or vasculitis, an repetitive trauma due to rose thorns was supposed to be the cause of the radial aneurysm. Anticoagulation therapy was initiated and infusion of prostaglanden E1 was performed over 7 days. The digital ischemia resolved within a few days. Therefore a surgical procedure was not recommended.

Question: Digital ischemia in a gardener: is rose cutting a vascular risk factor?

In the presence of a radial artery aneurysm an occupational and recreational trauma history should be sought after.

Answer the question based on the following context: Although there has been a tremendous amount of research examining the risk conferred for suicide by depression in general, relatively little research examines the risk conferred by specific forms of depressive illness (e.g., dysthymic disorder, single episode versus recurrent major depressive disorder [MDD]). The purpose of the current study was to examine differences in suicidal ideation, clinician-rated suicide risk, suicide attempts, and family history of suicide in a sample of outpatients diagnosed with various forms of depressive illness. To accomplish this aim, we conducted a cluster analysis using the aforementioned suicide-related variables in a sample of 494 outpatients seen between January 2001 and July 2007 at the Florida State University Psychology Clinic. Patients were diagnosed using DSM-IV criteria. Two distinct clusters emerged that were indicative of lower and higher risk for suicide. After controlling for the number of comorbid Axis I and Axis II diagnoses, the only depressive illness that significantly predicted cluster membership was recurrent MDD, which tripled an individual's likelihood of being assigned to the higher risk cluster. The use of a cross-sectional design; the relatively low suicide risk in our sample; the relatively small number of individuals with double depression.

Question: Do major depressive disorder and dysthymic disorder confer differential risk for suicide?

Our results demonstrate the importance of both chronicity and severity of depression in terms of predicting increased suicide risk. Among the various forms of depressive illness examined, only recurrent MDD appeared to confer greater risk for suicide.

Answer the question based on the following context: Automobile vs. pedestrian (AVP) injuries cause substantial morbidity and mortality. Gender may be an important factor in determining the anatomic distribution and severity of these injuries. The objective of this study was to examine the effect of gender on the nature and severity of automobile vs. pedestrian injuries and the outcome. Trauma registry study that included all AVP pedestrian injuries admitted during a 14-year period to a Level I trauma center. The following variables were included in an Excel (Microsoft Corporation, Redmond, WA) file for the purpose of this study: age, gender, body area Abbreviated Injury Score, Injury Severity Score, specific fractures (pelvic, spine, femur, tibia), survival, and intensive care unit (ICU) and hospital length of stay. The study population included 6965 patients, 67.3% of whom were male. Overall, 20.7% were in the age group<15 years, 60.5% in the age group 15-55 years, 7.6% in the age group 56-65 years, and 11.1% in the age group>65 years. Pelvic fractures were significantly more common in females than males (20.7% vs. 11.4%, respectively, p<0.0001). This difference was present in all age groups, but especially in the groups 56-65 years (28.5% vs. 12.3%, respectively, p<0.0001) and>65 years (32.5% vs. 15.7%, respectively, p<0.0001). Males in the age group 15-55 years were significantly more likely to suffer tibia fractures (31.8% vs. 25.7%, respectively, p<0.001). Multivariate analysis showed no difference in survival or ICU stay between the two genders, but there was a significantly longer hospital stay in males 15-65 years.

Question: Automobile versus pedestrian injuries: does gender matter?

Gender plays a significant role in the incidence of pelvic and tibial fractures but has no effect on survival or ICU stay, but male patients in the age group 15-65 years had a significantly longer hospital stay.

Answer the question based on the following context: Biliary tract cancer is uncommon, but has a high rate of early recurrence and a poor prognosis. There is only limited information on patients surviving more than 5 years after resection. We report a patient who developed recurrence 8 years after resection of cholangiocarcinoma. Descriptions of late recurrence after excision of cholangiocarcinoma are reviewed. Few long-term survivors with biliary tract cancer have been reported. The survivors tend to have well differentiated or papillary tumors. The present case had no recurrence for 8 years despite poor prognostic factors including poor differentiation, invasion through the muscle wall and perineural invasion. It has been suggested that tumor cells left after the first operation grow and present as late recurrence. There is a need to differentiate a new primary and field change from recurrence of the previous tumor.

Question: Late recurrence after surgery for cholangiocarcinoma: implications for follow-up?

Long-term follow-up after resection of cholangiocarcinoma is needed because late recurrence after 5 years occurs. The mortality rate between 5 and 10 years after resection of cholangiocarcinoma ranges from 6% to 43% in different series. Early detection of local recurrence may give an opportunity for further surgical resection.

Answer the question based on the following context: In the literature there is not available a uniformly accepted method for assessing the degree of obesity.AIM: To determine how far insulin resistance, serum levels of leptin and resistin are altered in persons categorized on the basis of body-mass index (BMI), body fat percentage, and abdominal circumference. 101 volunteer boys and 115 girls participated in the studies. Body height was measured, body mass, abdominal circumference, and body composition were determined by InBody3 bioimpedance instrument. Body mass index and body fat percentage were calculated by the instrument. Concentrations of serum glucose, insulin, leptin, and resistin were determined. Insulin resistance was calculated using the homeostasis model: HOMA IR . Body fat percentage, serum levels of leptin and resistin were significantly higher in girls than in boys. Increases in BMI, body fat percentage, and abdominal circumference were associated with the significant elevation of both HOMA IR and serum leptin concentrations. In overweight boys categorized by body fat percentage as obese the serum leptin concentrations were significantly higher than in their non-obese counterparts.

Question: Is there a unique measuring method to assess obesity?

Determination of body composition would be important concerning the follow-up of biochemical changes occurring in the body during the course of both epidemiological studies and nutritional interventions.

Answer the question based on the following context: Diffusion-weighted imaging (DWI) permits early detection and quantification of hypoxic-ischemic (HI) brain lesions. Our aim was to assess the predictive value of DWI and apparent diffusion coefficient (ADC) measurements for outcome in children with perinatal asphyxia. Term neonates underwent MR imaging within 10 days after birth because of asphyxia. MR imaging examinations were retrospectively evaluated for HI brain damage. ADC was measured in 30 standardized brain regions and in visibly abnormal areas on DWI. In survivors, developmental outcome until early school age was graded into the following categories: 1) normal, 2) mildly abnormal, and 3) definitely abnormal. For analysis, category 3 and death (category 4) were labeled "adverse," 1 and 2 were "favorable," and 2-3 and death were "abnormal" outcome. Differences in outcome between infants with and without DWI abnormalities were analyzed by using chi(2) tests. The nonparametric Mann-Whitney U test analyzed whether ADC values in visible DWI abnormalities correlated with age at imaging. Logistic regression analysis tested the predictive value for outcome of the ADC in each standardized brain region. Receiver operating characteristic analysis was used to find optimal ADC cutoff values for each region for the various outcome scores. Twenty-four infants (13 male) were included. Mean age at MR imaging was 4.3 days (range, 1-9 days). Seven infants died. There was no difference in outcome between infants with and without visible DWI abnormalities. Only ADC of the posterior limb of the internal capsule correlated with age. ADC in visibly abnormal DWI regions did not have a predictive value for outcome. Of all measurements performed, only the ADC in the normal-appearing basal ganglia and brain stem correlated significantly with outcome; low ADC values were associated with abnormal/adverse outcome, and higher ADC values, with normal/favorable outcome (basal ganglia: P = .03 for abnormal, P = .01 for adverse outcome; brain stem: P = .006 for abnormal, P = .03 for adverse outcome).

Question: Do apparent diffusion coefficient measurements predict outcome in children with neonatal hypoxic-ischemic encephalopathy?

ADC values in normal-appearing basal ganglia and brain stem correlated with outcome, independently of all MR imaging findings including those of DWI. ADC values in visibly abnormal brain tissue on DWI did not show a predictive value for outcome.

Answer the question based on the following context: Emergency medical service (EMS) staff in the UK routinely transport all emergency responses to the nearest emergency department (ED). Proposed reforms in the ambulance service mean that EMS staff will transport patients not necessarily to the nearest hospital, but to one providing facilities that the patient is judged to require. No previous UK studies have evaluated how accurately EMS staff can predict which transported patients will require admission to hospital. To survey EMS staff regarding the appropriate use of their service and determine whether they can predict which patients will require hospital admission. A prospective ''service evaluation'' of EMS staff transporting patients to an adult ED in the UK. Staff were asked to state whether ED attendance by emergency ambulance was appropriate and whether transported patients would be admitted or discharged from the ED. During the study period, there were 2553 emergency transports to the ED and questionnaires were completed in 396 cases (15.5%). EMS staff predicted that 182 (46.0%) would be admitted to hospital and 214 (54.0%) would be discharged. Actual dispositions were 187 (47.2%) versus 209 (52.8%) respectively. Sensitivity of predicting admission was 71.7% (95% CI 65 to 78) and specificity was 77.0% (95% CI 71 to 81). EMS staff were significantly better at predicting admission in non-trauma cases than trauma cases (75.9% vs 57.1%, 95% CI 2.2 to 35.4).

Question: Can emergency medical service staff predict the disposition of patients they are transporting?

Staff in one UK ambulance service showed reasonable accuracy when predicting the likelihood of admission of patients they transport. They correctly identified most patients who would be able to leave. Further work is needed to support these findings and ensure that EMS staff safely triage patients to alternative destinations of care.

Answer the question based on the following context: To evaluate the diagnostic performance of 50-g glucose challenge test for diagnosis of gestational diabetes. A retrospective study was conducted by reviewing the medical records of pregnant women who had a 50-g glucose challenge test of 140 mg/dL or higher and followed by a 100-g glucose tolerance test. Results were categorized in 10 mg/dL increments. Gestational diabetes was diagnosed using National Diabetes Data Group criteria. The present study included 2,226 cases from universal screening of 11,084 pregnant women. The incidence of gestational diabetes was 3.2% (351/11,084). Only 1.6% (6/374) of patients with positive screening results of less than 145 mg/dL had gestational diabetes. All of the 6 women undiagnosed by this threshold were gestational diabetes class A1 and had at least one risk factor Of 1,875 women, seven cases (0.4%) would be over diagnosed as gestational diabetes if 100-g glucose tolerance test was not performed after a result of 50-g glucose challenge test of>or = 250 mg/dL (99.6% specificity, 85.8% negative predictive value, 12.3% sensitivity and 86.0% positive predictive value).

Question: A 50-g glucose challenge test: is there any diagnostic cut-off?

A 50-g glucose challenge test may be used as a diagnostic test when the value is>or = 250 mg/dL. The present data suggested that the value of glucose screening of>or = 145 mg/dL can be used as a threshold for a positive test in the low risk women.

Answer the question based on the following context: Gestational diabetes affects approximately 7 percent of all pregnancies in the United States; its prevalence may have increased among all ethnic groups since the early 1990 s. Our study examined whether physical activity during pregnancy reduced the risk of gestational diabetes among women who were physically inactive before pregnancy. We used data from the 1988 National Maternal and Infant Health Survey (NMIHS), a nationally representative sample of mothers with live births. The NMIHS obtained mothers' gestational diabetes diagnoses from care providers and mothers reported their physical activity before and during pregnancy, including the number of months with physical activity and types of physical activity. We developed a physical activity index, the product of the number of months with physical activity, and average metabolic equivalents for specific activities. The analysis included 4,813 women who reported being physically inactive before pregnancy, with singleton births and no previous diabetes diagnosis. Gestational diabetes was diagnosed in 3.5 percent of the weighted sample in 1988. About 11.8 percent of these previously inactive women began physical activity during pregnancy. Women who became physically active had 57 percent lower adjusted odds of developing gestational diabetes than those who remained inactive (OR 0.43, 95% CI 0.20-0.93). Women who had done brisk walking during pregnancy had a lower adjusted risk of gestational diabetes (OR 0.44, CI 0.19-1.02) and women with a physical activity index score above the median had 62 percent lower odds of developing gestational diabetes than the inactive women (CI 0.15-0.96).

Question: Does physical activity during pregnancy reduce the risk of gestational diabetes among previously inactive women?

Results suggest that physical activity during pregnancy is associated with lower risk for gestational diabetes among previously inactive women.

Answer the question based on the following context: Although debate on factors associated with a high risk of cesarean delivery has continued for many years, only a few studies have explored the role of socioeconomic position. We studied the effect of educational level on risk of cesarean section in particular the different roles of maternal and paternal education. We analyzed all 88,698 firstborn live births registered between 1990 and 1996 to mothers who were residents of Rome at the time of delivery. Logistic regression was used to investigate the association between cesarean section and parent education, taking possible confounding factors into consideration. During the study period, the cesarean section rate was 32.5 percent. The direct association between level of education and cesarean delivery, found in the crude analysis, was completely reversed once maternal age was taken into account. Multivariate analyses showed that women with a primary school degree had a 24 percent (95% CI = 12-37) higher risk of cesarean delivery than those with a university degree. The association was even stronger for deliveries in public hospitals. Although both parents' level of education had an effect on the cesarean section rate, maternal education had a stronger effect than and was independent from paternal education.

Question: Are cesarean deliveries more likely for poorly educated parents?

Mothers with little education were consistently more likely to deliver by cesarean section than highly educated women, even when their partner's level of education was taken into account. Effective interventions aimed at reducing cesarean delivery rates in women of lower social class should be a priority for national health services, particularly in countries where the cesarean rate has been increasing.

Answer the question based on the following context: This study aimed to compare outcomes for mastoidotympanoplasty and for tympanoplasty alone in cases of quiescent, tubotympanic, chronic, suppurative otitis media. Single-blinded, randomised, controlled study within a tertiary referral hospital. Sixty-eight cases were randomly allocated into two groups. In group one, 35 ears underwent type one tympanoplasty along with cortical mastoidectomy. In group two, 33 ears underwent type one tympanoplasty alone. Outcome measures were as follows: perforation closure and graft uptake, hearing improvement, disease eradication, and post-operative complications. There were no statistically significant differences in hearing improvement, tympanic perforation closure, graft uptake or disease eradication, comparing the two groups at three and six months post-operatively.

Question: Cortical mastoidectomy in quiescent, tubotympanic, chronic otitis media: is it routinely necessary?

Mastoidotympanoplasty was not found to be superior to tympanoplasty alone over a short term follow-up period. Hence, it may not be necessary to undertake routine mastoid exploration at this stage of disease.

Answer the question based on the following context: Previous studies suggested the importance of peritraumatic reactions as predictors of PSTD symptoms severity. Despite mounting evidence that tonic immobility occurs under intense life threats its role as predictor of PTSD severity remains by and large understudied. The objective of this study was to investigate the role of peritraumatic reactions (tonic immobility, panic and dissociation) as predictors of PTSD symptoms severity. Participants were 32 victims of urban violence with PTSD diagnosed through the SCID-I. In order to evaluate PTSD symptoms at baseline, we used the Post-Traumatic Stress Disorder Checklist-Civilian Version. To assess peritraumatic reactions we employed the Physical Reactions Scale, the Peritraumatic Dissociative Experiences Questionnaire and Tonic Immobility questions. As confounding variables, we considered negative affect (measured by the Positive and Negative Affect Schedule-Trait Version), sex and time elapsed since trauma. Tonic immobility was the only predictor of PTSD symptoms severity that kept the statistical significance after controlling for potential confounders. This study was based on a relatively small sample recruited in a tertiary clinic, a fact that may limit the generalizability of its findings. The retrospective design may have predisposed to recall bias.

Question: Is tonic immobility the core sign among conventional peritraumatic signs and symptoms listed for PTSD?

Our study provides good reason to conduct more research on tonic immobility in PTSD with other samples and with different time frames in an attempt to replicate these stimulating results.

Answer the question based on the following context: To assess the effectiveness of an activity programme in improving function, quality of life, and falls in older people in residential care. Cluster randomised controlled trial with one year follow-up. 41 low level dependency residential care homes in New Zealand. 682 people aged 65 years or over. 330 residents were offered a goal setting and individualised activities of daily living activity programme by a gerontology nurse, reinforced by usual healthcare assistants; 352 residents received social visits. Function (late life function and disability instruments, elderly mobility scale, FICSIT-4 balance test, timed up and go test), quality of life (life satisfaction index, EuroQol), and falls (time to fall over 12 months). Secondary outcomes were depressive symptoms and hospital admissions. 473 (70%) participants completed the trial. The programme had no impact overall. However, in contrast to residents with impaired cognition (no differences between intervention and control group), those with normal cognition in the intervention group may have maintained overall function (late life function and disability instrument total function, P=0.024) and lower limb function (late life function and disability instrument basic lower extremity, P=0.015). In residents with cognitive impairment, the likelihood of depression increased in the intervention group. No other outcomes differed between groups.

Question: Does a functional activity programme improve function, quality of life, and falls for residents in long term care?

A programme of functional rehabilitation had minimal impact for elderly people in residential care with normal cognition but was not beneficial for those with poor cognition. Trial registration Australian Clinical Trials Register ACTRN12605000667617.

Answer the question based on the following context: Some beverages are nutrient dense, but they are often excluded from nutrient density calculations. The purpose of this study was to assess whether the energy-nutrient association changed when beverages were included in these calculations. Applying a cross-sectional design, a 24-hour dietary recall was collected on each participant. Subjects/ 440 young adults (ages 19-28 years) in Bogalusa, Louisiana participated in this study. Mean nutrient intakes and food group consumption were examined across the energy density (ED) tertiles using two calculation methods: one with food and all beverages (excluding water) (ED1) and one including food and only energy containing beverages (ED2). Regression models were used and multiple comparisons were performed using the Tukey-Kramer procedure. A p-value<0.05 was considered to be significant. With increasing ED, there was a significant increase in the consumption of total meats (ED1 p<0.05; ED2 p<0.01). In contrast, there was a significant decrease in consumption of fruits/juices (ED1 p<0.01; ED2 p<0.0001), vegetables (ED1 p<0.01; ED2 p<0.05), beverages (both p<0.0001) and total sweets with increasing ED (both p<0.0001). There was a significantly higher mean intake of total protein (grams) (ED2 p<0.0001), amino acids (ED1 histidine/leucine p<0.05; ED2 p<0.0001), and total fat (grams) (ED1 p<0.0001; ED2 p<0.0001) with higher ED compared to lower ED. The percent energy from protein (ED1 p<0.05; ED2 p<0.0001), total fat (both p<0.001) and saturated fatty acids (both p<0.0001) significantly increased and the percent energy from carbohydrate (both p<0.0001) and sucrose (both p<0.0001) significantly decreased with increasing ED.

Question: Are energy dense diets also nutrient dense?

This study suggests that ED may influence the ND of the diet depending on whether energy containing beverages are included or excluded in the analysis.

Answer the question based on the following context: Prediction of short- and long-term prognosis is an important issue in acute stroke care. This metaanalysis explores the prognostic value of initial bed-side transcranial ultrasound in acute stroke. All studies prospectively applying TCCS or TCD within 24 hours of symptom onset in acute stroke, with a minimal cohort size of 20 patients, and reporting clinical outcome variables in relation to the vascular findings were included into this metaanalysis. Study quality was assessed by 2 independent reviewers. Twenty-five studies with 1813 included patients identified by electronic and manual search fulfilled the inclusion criteria. Middle cerebral artery (MCA) occlusion was associated with a significantly increased risk for a fatal course of stroke (OR 2.46, 95% CI 1.33 to 4.52). Patients with patent MCA were more likely to clinically improve within 4 days than patients with MCA occlusion (OR 11.11, 95% CI 5.44 to 22.69). Full recanalization within 6 hours after symptom onset was highly significantly associated with clinical improvement within 48 hours (OR 5.64, 95% CI 3.82 to 8.31) and functional independence after 3 months (OR 6.07, 95% CI 3.94 to 9.35).

Question: Can early neurosonology predict outcome in acute stroke?

Transcranial ultrasound provides important information on prognosis in patients with acute stroke.

Answer the question based on the following context: Smaller kidney lesions which are more often detected recently by accidental imaging are amenable for nephron sparing approach whether at open surgery, laparoscopy or ablative techniques. The pretreatment planning is based on multiplanner CT expected to well define the relationship of the lesion to the major renal blood vessels and collecting system (CS). This study is aimed to compare the pre-surgical CT measurements of the distance from tumor to CS to the actual distances observed on radical nephrectomy specimens. Contrast CT of 39 patients with renal cell carcinoma (RCC) underwent measurements of the distance between CS and renal tumor. All measurements were confronted with the measurements performed on radical nephrectomy specimens of the same patients. Of all 39 patients in 34 (87%) CT showed a contact relation between the tumor and the CS. In fact, the CS involvement has been histologically proven only in three (7.6%) cases. Cutting off the measurements at thresholds of 2 and 5 mm also showed a significant discrepancy between CT and specimen measurements.

Question: Collecting system involvement by renal tumor: are CT measurements reliable enough?

The trend of NSS and ablative techniques stressed out the importance of pretreatment measurements of the distance between the tumor and the CS. This study as performed on radical nephrectomy specimens points out the overestimated proximity of the tumor to the CS. These data if confirmed by other studies, may play a role while planning the management of NS approaches.

Answer the question based on the following context: Spontaneous pneumomediastinum is a rare entity that usually occurs in young males without any apparent precipitating factor. Several case series have been published focusing on clinical features, workup and prognosis. Due to the rarity of this entity, there is no consensus on the most appropriate treatment. To describe the clinical characteristics and course of patients with spontaneous pneumomediastinum in our institution. This retrospective descriptive study was based on a review of the charts of all patients discharged from our hospital with a diagnosis of SPM during the period 2000 to 2007. Thirteen patients were identified and information on their clinical presentation, course, hospital stay, investigations and outcome was gathered. In 70% of patients the presenting complaint of SPM was pleuritic chest pain, while 30% of patients developed SPM in the course of another respiratory illness. Subcutaneous emphysema was the most common clinical finding (46%). Chest X-ray was diagnostic in 12 of 13 patients, and additional tests such as esophagogram and echocardiogram were unrevealing. Leukocytosis and electrocardiographic changes in inferior leads were seen in 30% of patients. Mean hospital stay was 48 hours, treatment was supportive, and symptomatic improvement was usually noted within 24 hours. No recurrences occurred.

Question: Spontaneous pneumomediastinum: is a chest X-ray enough?

SPM is a rare entity that should be considered in patients with pleuritic chest pain. Treatment is supportive, and if no clues for esophageal rupture are present, investigations other than chest X-ray are probably not warranted. It is safe to discharge the patient within 24 hours provided that symptomatic improvement is achieved.

Answer the question based on the following context: Children report various types of fear in the context of hospitalization, such as fear of separation from the family, having injections and blood tests, staying in the hospital for a long time, and being told "bad news" about their health. To examine the effects of the "Teddy Bear Hospital" method on preschool children's fear of future hospitalization. The study group comprised 41 preschool children aged 3-6.5 years (mean 5.1 +/- 0.7 years), and 50 preschool children, age matched and from a similar residential area, served as the control group. Assessment included a simple one-item visual analog scale of anxiety about hospitalization. This was assessed individually one day prior to the intervention and again a week after the intervention in both groups. While baseline levels of anxiety were not different between groups [t(89) = 0.4, NS], children in the "Teddy Bear Hospital" group reported significantly lower levels of anxiety than the control group at follow-up.

Question: Doctor, is my teddy bear okay?

Our results indicate that by initiating a controlled pain-free encounter with the medical environment in the form of a "Teddy Bear Hospital", we can reduce children's anxiety about hospitalization.

Answer the question based on the following context: Undernutrition is common in older hospitalised patients, and routine screening is advocated. It is unclear whether screening tools such as the Birmingham Nutrition Risk (BNR) score and the Malnutrition Universal Screening Tool (MUST) can successfully predict outcome in this patient group. Consecutive admissions to Medicine for the Elderly assessment wards in Dundee were assessed between mid-October 2003 and mid-January 2004. Body Mass Index (BMI), MUST and BNR scores were prospectively collected. Time to death was obtained from the Scottish Death Register and compared across strata of risk. 115 patients were analysed, mean age 82.1 years. 39/115 (34%) were male. 20 patients were identified as high risk by both methods of screening. A further 10 were categorised high risk only with the Birmingham classification and 12 only with MUST.80/115 (67%) patients had died at the time of accessing death records. MUST category significantly predicted death (log rank test, p = 0.022). Neither BMI (log rank p = 0.37) or Birmingham nutrition score (log rank p = 0.35) predicted death.

Question: Do the malnutrition universal screening tool (MUST) and Birmingham nutrition risk (BNR) score predict mortality in older hospitalised patients?

The MUST score, but not the BNR, is able to predict increased mortality in older hospitalised patients.

Answer the question based on the following context: In this study, we aimed to investigate the differences between a sample of migraineurs and non-migraineurs with regard to their stress symptoms, tendency to stress, coping styles and life satisfaction. This study was carried out on a migraineur group (n = 62, mean age: 37.5 +/- 11.3, range: 18 to 61 years) and a non-migraineur group (n = 58, mean age: 32.0 +/- 11.2, range: 18 to 61 years). Stress Audit (Symptoms), Stress Audit (Vulnerability), Turkish version of Ways of Coping Inventory Scales and Life Satisfaction were applied to the migraineur and non-migraineur groups. No significant differences were found between the groups in the scores of the stress symptoms except in the sub scores of the sympathetic system. There was no significant difference between the groups in the tendency to stress and life satisfaction (p>.05). For scores of the coping styles, the mean scores of the seeking social support subscale was higher in the control group than that of the migraineur group. However, migraineur women had higher mean scores in the submissive and the optimistic subscales.

Question: Are migraineur women really more vulnerable to stress and less able to cope?

We consider that, these outcomes may emphasize the necessity to be careful when using negative expressions about stress relating to migraineurs. Further comprehensive studies are required considering the multiple triggers of the disease in various cultural contexts.

Answer the question based on the following context: This study was conducted to assess the prevalence of lower genital tract infections with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae among women seeking first-trimester pregnancy termination in a same-day abortion clinic in a public hospital. We reviewed CT and N. gonorrhoeae test results of 1974 women who underwent a first-trimester abortion for a period of 6 months between January 1, 2006, and June 30, 2006, at a large public hospital. During our study period, 225 (11.4%) women tested positive for chlamydia infection and 51 (2.6%) women tested positive for gonorrhea using probe technology. Twenty-two (1.2%) women tested positive for both.

Question: Prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae genital infections in a publicly funded pregnancy termination clinic: empiric vs. indicated treatment?

We found a comparatively high prevalence rate of chlamydia-positive patients (11.4%) in our publicly funded pregnancy termination clinic. Because of infrequent follow-up in this patient population, we suggest screening and providing the epidemiologic treatment for CT genital infection for all women undergoing a same-day abortion procedure. It may prove cost-effective. Our prevalence rate of gonorrhea was lower (2.6%). The value of providing epidemiologic treatment for gonorrhea to all patients undergoing a same-day abortion procedure should be reexamined in controlled trials.

Answer the question based on the following context: Chronic inflammation (CI) is commonly found in the anal transition zone (ATZ) after stapled ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). Yet, its impact on defecatory function and the need for a complete mucosectomy has not been completely elucidated. This study aims to evaluate the long-term functional outcomes of patients with CI of the ATZ after stapled IPAA in comparison with mucosectomy patients. Between June 1987 and November 2007, 66 UC patients were found to have CI of the ATZ after stapled IPAA and were compared with 228 UC patients who underwent mucosectomy with hand-sewn (HS) IPAA. Patients were mailed a questionnaire to assess defecatory function and quality of life. Data were analyzed prospectively. No differences were observed in age, sex, number, or consistency of bowel movements (BMs) between groups. Complete continence was reported by 90.3% of CI and 66.8% of HS patients (P<.001). The CI group also had a significantly lower rate of major incontinence (P<.001). Functional parameters in favor of the CI group included the ability to discriminate between gas and stool (P<.001), the use of protective pads during both the day and the night (P<.001), dietary modifications in the timing of meals (P<.001) and type of food (P = .005), and the presence of perianal rash (P = .019). In the CI group, more patients rated their quality of life as improved from before the operation (P<.001).

Question: Chronic inflammatory changes in the anal transition zone after stapled ileal pouch-anal anastomosis: is mucosectomy a superior alternative?

Preservation of the ATZ, even in presence of persistent inflammation, confers improved continence, better functional outcomes, and superior quality of life.

Answer the question based on the following context: Arthroscopic surgery has been shown to be an effective treatment for patients with temporomandibular disorders, relieving patients' symptoms and restoring adequate mandibular function. For those patients with poor arthroscopic outcomes, various treatment modalities are possible, such as nonsurgical therapy, open surgery, or repeat arthroscopic surgery. The purpose of this study was to evaluate our results with rearthroscopy in patients with temporomandibular joint dysfunction. The clinical data and operative reports for 50 patients who underwent a second arthroscopic procedure from 1994 to 2004 were reviewed retrospectively. Outcome assessments were based on reductions in pain, measured using a visual analog scale, and improvements in maximal interincisal opening. The minimum follow-up period was 2 years. Significant differences were evident between presurgical and postsurgical pain at months 1, 6, 12, and 24. The mean score of preoperative pain on the visual analogue scale was 61.65 mm, which was reduced to 36.28 mm at 2-year follow-up. With regard to mandibular function, all patients presented with restricted mouth opening, with a mean preoperative maximal interincisal opening of 26.73 mm. Postoperatively, the maximal interincisal opening showed a statistically significant improvement (P<.05), and at 2-year follow-up, we obtained a total improvement of 7 mm. Only 8 patients (16%), who had an unsuccessful result after a second arthroscopy, underwent further surgical intervention (open surgery).

Question: Unsuccessful temporomandibular joint arthroscopy: is a second arthroscopy an acceptable alternative?

Arthroscopic surgery is a reliable and effective procedure for temporomandibular joint dysfunction that improves pain and mouth opening, with the advantages of being minimally invasive and repeatable. Repeat arthroscopic surgery, with a proven history of fewer complications, can be attempted before open arthrotomy.

Answer the question based on the following context: The purpose of this retrospective cohort study was to analyze the complications associated with a series of mandibular angle fractures treated by open reduction and internal fixation and to determine if the method of intraoperative maxillomandibular fixation (MMF) affected patient outcome. The records of 162 consecutive patients with isolated mandibular fractures that were treated by the senior author (R.B.B.) with open reduction and internal fixation were retrospectively reviewed and a number of clinical variables were recorded. Of these, all patients with fractures involving the mandibular angle, alone or in combination with other mandibular fractures, were identified. Only patients in the permanent dentition with angle fractures treated with a single 2.0 mm titanium plate placed at the superior border using standard Champy technique were included in the study. Patients with less than 6 weeks follow-up, concomitant midface fractures, edentulous patients, patients with comminuted fractures or gunshot wounds, and those patients presenting with infected fractures were excluded from the primary study group, which totaled 75 patients with 83 angle fractures. Postoperative complications, including infection, malunion/nonunion, wound dehiscence, osteomyelitis, pain, and the need for secondary operative intervention, were tabulated. For purposes of comparison, patients were divided into 3 groups based upon the type of intraoperative MMF utilized: group 1, Erich arch bars (n = 24); group 2, 24 gauge interdental "Stout" wires (n = 25); and group 3, manual reduction alone (n = 26). Outcome measures were defined as successful bone healing, acceptable occlusion, minor complications, and major complications. Descriptive statistics were recorded and an analysis of variance was calculated to evaluate differences between the 3 groups. The Fisher's exact test was used to evaluate whether a complication occurred more frequently in any one particular group. The mean age of the 75 patients included in the study was 28.2 years (M = 63, F = 12) and there were no significant demographic differences between the 3 groups (P = 0.22). All patients eventually achieved successful bony union with an acceptable occlusion. Thirty-two percent of patients in the cohort required a second procedure, usually outpatient removal of loose or symptomatic hardware under local anesthesia or intravenous sedation, but there was no difference in re-operation rate based upon the method of intraoperative fixation (P = .47). Major complications occurred in 2 patients that required secondary operations due to malunion and nonunion (2.7%). Twenty-two minor complications occurred in 16 patients (21.3%) and were evenly distributed amongst the 3 groups (P = .074), including infection (n = 4), wound dehiscence (n = 1), and/or symptomatic hardware (n = 16) that required hardware removal. All of the minor complications were treated in an outpatient setting under local anesthesia or under intravenous sedation. When the complications were pooled together, the Fisher exact test again yielded no difference in complications between the 3 groups (P = .33).

Question: Is the use of arch bars or interdental wire fixation necessary for successful outcomes in the open reduction and internal fixation of mandibular angle fractures?

The use of Erich arch bars or interdental wire fixation to assist with MMF during the open reduction and internal fixation of noncomminuted mandibular angle fractures treated in Champy fashion is not always necessary for successful outcome.

Answer the question based on the following context: Women with fertility problems experience a higher prevalence of negative emotions than women without fertility problems. The goal of this study was to compare the effects of psychological intervention with psychotropic medication on the mental health improvement of depressed infertile women. In a randomized controlled clinical trial, 89 depressed infertile women that they were recruited and divided into three groups in three groups: cognitive behavior therapy (CBT), antidepressant therapy, and a control group. Twenty-nine participants in the CBT method received 10 sessions on relaxation training, restructuring, and eliminating negative automatic thoughts and dysfunctional attitudes to infertility. Thirty participants in the pharmacotherapic group took 20mg fluoxetine daily for 90 days. Thirty control subjects did not receive any intervention. All participants completed the Beck Depression Inventory (BDI) and the General Health Questionnaire (GHQ) at the beginning and end of the study. Paired t-test, ANOVA, chi(2), and McNemar tests were used to analyze the data. Fluoxetine significantly reduced the mean of three subscale scores of the GHQ anxiety (7.3+/-4.1 vs. 5.1+/-3.2), social function (7+/-2.8 vs. 4.3+/-2), and depression (7.8+/-5.2 vs. 4.4+/-2.2) but could not significantly change the mean score of psychosomatic signs. The CBT method effectively reduced the mean of all four GHQ subscales: anxiety (8+/-4 vs. 3.2+/-2), social function (7.2+/-2.6 vs. 4.7+/-2.5), depression (7.7+/-4.2 vs. 3.6+/-2.7), and psychosomatic signs (7.5+/-3.2 vs. 5.5+/-3.2). Also, both methods significantly reduced the total GHQ scores. Successful treatment of depression in three groups was fluoxetine group 50%, CBT 79.3%, and control 10%. The mean Beck scores among the groups at the beginning and end of study were, respectively: fluoxetine 23.2+/-8.6 versus 14.3+/-8.5 (p<0.001), CBT 20+/-7.9 versus 7.7+/-4.8 (p<0.001), and control 19.8+/-8.5 versus 19.7+/-8.4 (p=0.9). Although both fluoxetine and CBT significantly decreased the mean BDI scores more than the control group, the decrease in the CBT group was significantly greater than the fluoxetine group.

Question: Is psychotherapy a reliable alternative to pharmacotherapy to promote the mental health of infertile women?

Psychotherapy, such as group CBT, was superior to or at least as effective as pharmacotherapy to promote the well being of depressed infertile women.

Answer the question based on the following context: In elderly patients, the prognosis of acute coronary syndrome is bleak and the impact of geriatric factors is as yet unknown. The purpose of this work was to identify factors predictive of poor outcome at Month 6 in a population of elderly subjects admitted into hospital with acute coronary syndrome. One hundred and thirty-two patients over 80 years of age were compared with 127 patients under 80, all admitted into a cardiology intensive care unit with acute coronary syndrome between May 2006 and January 2007, vis-à-vis outcome, mortality and cardiovascular events, both during the hospital stay and six months later. Coronary angiography was performed in fewer of the over-80 group (85.6% versus 97.7%, p<0.001) but revascularisation rates were comparable in both groups (75.6% versus 78.9%, p=0.58). During the hospital stay, the incidence of complications was higher (68.8% versus 38.1%, p<0.0001) in the older patients as was mortality (18.2% versus 3.2%, p=0.0001). At Month 6, all-cause mortality was higher in the octogenarians (28.0% versus 10.6%, p<0.001). The independent variables associated with Month 6 all-cause mortality in the over-80 group were: systolic blood pressure of less than 100mmHg, an admission heart rate of over 100bpm, a history of cardiovascular disease, acute coronary syndrome with ST segment elevation in the anterior territory, and the absence of chest pain.

Question: Are there specific prognostic factors for acute coronary syndrome in patients over 80 years of age?

In elderly patients admitted into hospital with acute coronary syndrome, geriatric parameters do not seem to affect prognosis which is dominated by cardiac variables.

Answer the question based on the following context: The pain-relieving efficacy of antagonists of histamine 1 (H1) receptors that are widely found in the ureter and that cause contractions in renal colic was presented in comparison with a placebo. Eighty-six patients who presented to the emergency service because of renal colic accompanied by nausea, and who had urinary system stones detected were included in the study. The patients were separated into 2 groups by double-blind, random assignment. The 45 patients in group 1 received 50 mg intramuscular (IM) dimenhydrinate. The 41 patients in group 2 received 2 mL IM saline solution as a placebo. The visual analogous scale (VAS) values were detected at referral of the patients and at 10, 20, and 30 minutes of therapy to detect the pain intensity. Verbal descriptive scale (VDS) was used for evaluation of nausea and vomiting before and after the therapy. VAS values were statistically quite low in group 1 at 10, 20, and 30 minutes of therapy. VDS scores were also statistically significantly low in group 1 at 30 minutes of treatment.

Question: Histamine 1 receptor antagonist in symptomatic treatment of renal colic accompanied by nausea: two birds with one stone?

Dimenhydrinate, which is an ethanolamine group H1 receptor blocker, appeared to be effective compared with the placebo in relieving renal colic pain and nausea and vomiting symptoms in patients. Comparative studies with other analgesics will be useful for determining how to use this agent for analgesic purposes in renal colic.

Answer the question based on the following context: Prior studies have demonstrated that transfusion of older stored blood is associated with an increased risk of multiple organ failure, infection, and death. These reports were primarily comprised of severely injured patients, and it remains unknown whether this phenomenon is observed in relatively less injured patients. The purpose of this study was to evaluate the association between the age of stored blood and the morbidity and mortality in a mild to moderately injured patient cohort. Blunt trauma patients with Injury Severity Score<25 admitted to a Trauma Intensive Care Unit during 7.5 years who received no blood during the first 48 hours of hospitalization were selected for inclusion. Patients who died within 48 hours of admission were excluded from analysis. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for the association between morbidity or mortality and the age and amount of blood transfused (>48 hours postadmission), adjusted for age, sex, injury severity, thoracic injury, mechanical ventilation, and transfusion volume. During 7.5 years, 1,624 patients met the study criteria. The mean Injury Severity Score was 14.4. Receipt of blood stored beyond 2 weeks was associated with mortality (OR 1.12 [CI 1.02-1.23]), renal failure (OR 1.18 [CI 1.07-1.29]), and pneumonia (OR 1.10 [CI 1.04-1.17]). No such associations were identified, however, concerning the transfusion of blood with a lesser storage age.

Question: Transfusions in the less severely injured: does age of transfused blood affect outcomes?

In a mild to moderately injured intensive care unit patient cohort, the receipt of blood stored beyond 2 weeks was independently associated with mortality, renal failure, and pneumonia. The deleterious effect of older blood on patient outcome does not appear to be limited to the severely injured.

Answer the question based on the following context: The aim of the study was to determine the effect of removal of a failed kidney allograft on the outcome of subsequent transplant. Retrospective analytical study comparing graft survival for patients (1993-2005) who had previous graft nephrectomy with those who had not. Of 89 patients with kidney re-transplants, 68 had had a transplant nephrectomy (Group I) while 21 had retained failed grafts (Group II). There was no significant difference in the two groups in the PRA level at the time of re-transplantation (37% versus 29%). Mean follow-up was 47 months. Acute rejections in Group I were 49.1% and in Group II, 31.2% (P = 0.20). Twenty (29%) grafts failed in Group I and four (19%) in Group II. One, three and five years' actuarial graft survival in Group I was 83.8%, 76% and 66.2%, while in Group II, it was 94.7%, 86.8% and 69.5%, respectively (P = 0.66). Five-year actuarial patient survival in Groups I and II was 94.1% and 87.5%, respectively (P = 0.69). Multivariate analysis showed that PRA level significantly influenced graft survival independent of nephrectomy (P = 0.04).

Question: Does nephrectomy of failed allograft influence graft survival after re-transplantation?

Nephrectomy of a failed allograft does not seem to significantly influence the survival of a subsequent graft.

Answer the question based on the following context: This case was analysed in the light of a careful literature review. This was an unusual case of failed suicide, attempted by a 94-year-old woman who had planned the suicide several days earlier.

Question: An uncommon case of failed suicide in a 94-year-old woman: "masked" depression or rational decision?

The unusual features of this case relate to: 1) the person's female gender and very advanced age; 2) her apparently "successful aging" condition; 3) the violent method and unusual means she used; 4) the suicide note written several days beforehand.

Answer the question based on the following context: Noncompaction of left ventricular myocardium is a rare congenital cardiomyopathy resulting from an incomplete myocardial morphogenesis that leads to the persistence of the embryonic myocardium. This condition is characterized by a thin compacted epicardial and an extremely thickened endocardial layer with prominent trabeculations and deep intertrabecular recesses. It is not clear, in noncompaction of myocardium, whether intertrabecular recesses could be responsible for thrombi formation and thromboembolic complications. The prevalence of stroke and echocardiographic finding of thrombus was evaluated in a continuous series of 229 patients (men and women) affected by noncompaction of the left ventricular myocardium, who were included in the SIEC registry. We excluded patients affected by atrial fibrillation. The mean age of the patients was 49.5 years. Fifty percent of the patients were affected by a ventricular systolic dysfunction. The mean period of follow-up was 7.3 years. Only four patients had a history of ischemic stroke. A large thrombus into the left ventricular chamber was observed in a 1-year-old child affected by Behcet's disease (high risk of thrombi formation).

Question: Anticoagulant drugs in noncompaction: a mandatory therapy?

Noncompaction of the left ventricular myocardium, by itself, does not seem to be a risk factor for stroke or embolic results, so there is no indication for oral anticoagulant therapy.

Answer the question based on the following context: This study investigated whether work dedication and job resources are longitudinally related to work-related musculoskeletal disorders and whether job resources buffer the impact of job demands on these disorders? Data were used from a longitudinal three-phase study (2004, 2005, 2006) on health at work among a sample of Dutch workers. The first survey was sent in 2004 by e-mail to 3100 members of an existing panel. For the analyses, 1522 participants were included with full longitudinal data. The analyses were performed using an autoregressive model with generalized estimating equations. The job-resource quality of communication was found to predict the risk of work-related musculoskeletal disorders over time. This effect was not mediated by work dedication. A high quality of communication was also found to buffer the negative effects of a high physical workload on the risk of work-related musculoskeletal disorders. Furthermore, a low level of social support by colleagues was found to buffer the negative effect of a medium physical workload on work-related musculoskeletal disorders.

Question: Can favorable psychosocial work conditions and high work dedication protect against the occurrence of work-related musculoskeletal disorders?

This study shows that job resources are not only important for promoting work dedication, but may also moderate the negative impact of high job demands on the risk of work-related musculoskeletal disorders. With respect to social support, the question is raised of whether this can also work negatively. The results of this study imply that, besides avoiding or reducing risks to health in the workplace and lowering job demands, strengthening job resources may additionally buffer harmful effects of job demands on musculoskeletal health.

Answer the question based on the following context: The role of haemofiltration as an adjunctive treatment of sepsis remains a contentious issue. To address the role of dose and to explore the biological effects of haemofiltration we compared the effects of standard and high-volume haemofiltration (HVHF) in a peritonitis-induced model of porcine septic shock. Randomized, controlled experimental study. Twenty-one anesthetized and mechanically ventilated pigs. After 12 h of hyperdynamic peritonitis, animals were randomized to receive either supportive treatment (Control, n = 7) or standard haemofiltration (HF 35 ml/kg per h, n = 7) or HVHF (100 ml/kg per hour, n = 7). Systemic and hepatosplanchnic haemodynamics, oxygen exchange, energy metabolism (lactate/pyruvate, ketone body ratios), ileal and renal cortex microcirculation and systemic inflammation (TNF-alpha, IL-6), nitrosative/oxidative stress (TBARS, nitrates, GSH/GSSG) and endothelial/coagulation dysfunction (von Willebrand factor, asymmetric dimethylarginine, platelet count) were assessed before, 12, 18, and 22 h of peritonitis. Although fewer haemofiltration-treated animals required noradrenaline support (86, 43 and 29% animals in the control, HF and HVHF groups, respectively), neither of haemofiltration doses reversed hyperdynamic circulation, lung dysfunction and ameliorated alterations in gut and kidney microvascular perfusion. Both HF and HVHF failed to attenuate sepsis-induced alterations in surrogate markers of cellular energetics, nitrosative/oxidative stress, endothelial injury or systemic inflammation.

Question: High versus standard-volume haemofiltration in hyperdynamic porcine peritonitis: effects beyond haemodynamics?

In this porcine model of septic shock early HVHF proved superior in preventing the development of septic hypotension. However, neither of haemofiltration doses was capable of reversing the progressive disturbances in microvascular, metabolic, endothelial and lung function, at least within the timeframe of the study and severity of the model.

Answer the question based on the following context: To determine if 1) there is cross contamination between odours tested on thresholds achieved, 2) a delay period is necessary between testing different odours. Thirty-five subjects underwent threshold testing with phenethyl alcohol (PEA), ethylmercaptan (MER), acetic acid (ACE), and eucalyptol (EUC) using serial logarithmic dilutions. On separate occasions subjects were exposed to high concentrations of PEA, ACE and EUC in random order for two minutes, and thresholds for all four odours re-tested. Pre- and post-high concentration odour thresholds were compared. Exposure to high concentrations of PEA, ACE and EUC does not alter olfactory thresholds by more than 10-2 for the other odours except in specific circumstances with ACE and EUV.

Question: Does odour cross contamination alter olfactory thresholds in certain odours?

There is limited cross contamination with ACE and EUC, which is avoided by specifying presentation order as: PEA, MER, ACE, EUC. Odours PEA, MER, ACE and EUC are recommended for olfactory testing.

Answer the question based on the following context: Measurement of Peak Nasal Inspiratory Flow (PNIF) seems to be a cheap and easily performed method to assess nasal patency. As demonstrated in a previous work, PNIF is influenced by SEX, AGE and HEIGHT. However there is a large degree of between-patient variability in PNIF levels. The purpose of this analysis is to determine whether the measurement of the pulmonary ventilatory capacity, by mean of Peak Expiratory Flow (PEF), enables more precise determination of PNIF. Repeated measurements of PNIF and PEF were performed in 112 volunteers. 100 of these fulfilled the study criteria (55 females and 45 males) and all of them were non-smokers, non-asthmatic, without nose and paranasal sinuses problems, with ages ranging from 15 to 71 years. Statistical analysis was undertaken to determine whether a relationship existed between PNIF and age, sex and height, but which also considered PEF. The data from both experiments were analysed together. In both groups there is a clear tendency for PNIF to increase with PEF. As clearly demonstrated in this work the value of PEF is informative in predicting PNIF and that the larger the value of PEF, the larger the value of PNIF.

Question: Does peak nasal inspiratory flow relate to peak expiratory flow?

PNIF is a useful method to study nasal patency in both primary and secondary care to aid diagnosis of nasal disease, but low values of PNIF have to be confirmed by a study of the PEF as PNIF low values may be an expression of low ventilatory activity rather than an expression of nasal obstruction.

Answer the question based on the following context: [18F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) is a powerful tool for the imaging of various lymphomas. Despite its high FDG avidity, there is little data on PET in follicular lymphoma (FL). In this work, we present findings concerning PET at staging and posttreatment evaluation in FL. A total of 181 PET scans were evaluated in 117 patients with FL in a retrospective study. Positron emission tomography-based results were compared with conventional staging in 82 patients. Posttreatment PET evaluation was performed in 99 patients; there were comparable progression-free survivals of PET-positive and PET-negative patients. Positron emission tomography showed more involvement than computed tomography (CT) with clinical examination in 41 of 82 patients (50%), less in 11 of 82 (13%); the same extension was found in 27 of 82 patients (33%), and 3 patients revealed discordant foci visible on PET only and lymphadenopathy without PET activity (P<.001). Including the results of trephine biopsy, PET finally upstaged FL in 15 of 82 patients (18%), which was projected in change of treatment strategy. There were 73 of 99 negative posttreatment PET scans; 54 of 73 PET-negative patients (74%) remain in complete remission (median follow-up, 27 months); 19 (26%) of them relapsed with median of 12 months. Fourteen of 20 (70%) PET-positive patients relapsed with a median of 4.5 months regardless of findings on CT and subsequent therapy. The difference in relapse rates between PET-positive and PET-negative patients is statistically significant (P<.001).

Question: Value of [18F]fluorodeoxyglucose positron emission tomography in the management of follicular lymphoma: the end of a dilemma?

Positron emission tomography at staging is able to substantially change treatment strategy in an important proportion of patients with FL. Persisting PET positivity after treatment predicts for a high risk of an early relapse and can identify patients with poor prognosis.

Answer the question based on the following context: Storage of embryos for fertility preservation before chemotherapy is widely practiced. For multiple oocyte collection, the ovaries are hyperstimulated with gonadotrophins that significantly alter ovarian physiology. The effects of ovarian stimulation prior to chemotherapy on future ovarian reserve were investigated in an animal model. Cyclophosphamide (Cy) in doses of 0, 50 or 100 mg/kg was administered to 38 adult mice (control, unstimulated). A second group of 12 mice were superovulated with equine chorionic gonadotrophin (eCG, 10 IU on Day 0) before Cy administration; hCG (10 IU) was administered (Day 2) followed by 0, 50 or 100 mg/kg Cy (Day 4). In both groups ovaries were removed, serially sectioned (7-day post-Cy), primordial follicles were counted and differences between groups evaluated. Follicle number dropped from 469 +/- 24 (mean +/- SE) to 307 +/- 27 and 234 +/- 19 with 50 or 100 mg/kg Cy, respectively (P<0.0001). In the eCG pretreated group, follicle count dropped from 480 +/- 31 to 345 +/- 16 and 211 +/- 26 when 50 or 100 mg/kg Cy were administered (P<0.0001). There were no significant differences in follicle count between the pretreated eCG group and controls for each chemotherapy dose.

Question: Does controlled ovarian stimulation prior to chemotherapy increase primordial follicle loss and diminish ovarian reserve?

This animal study indicates that ovarian stimulation before administration of Cy does not adversely affect ovarian reserve post-treatment. These results provide support for the safety of fertility preservation using ovarian stimulation and IVF-embryo cryopreservation procedures prior to chemotherapy.

Answer the question based on the following context: To compare rates of mammography screening among women in family practices, based on a sequential sample of eligible women presenting to the practices during an 8-week period, with rates found in a full audit of all eligible patients. Chart review. Twenty community-based family practices in south-central Ontario. Family physicians and their female patients 52 to 71 years old who had had at least 1 visit to the office during the past 3 years. Eligible patients were sampled by 2 approaches: sequential sampling of patients coming for appointments during an 8-week period and a full practice audit of all eligible women. Mammography rates found using the 2 approaches. The mean time-appropriate rate of mammography screening based on the sequential sample was 66.4%. The mean time-appropriate rate of mammography screening for the full practice audit was 58.8%. The sequential sample rate was higher than that of the full audit by 7.6%; differences ranged from -6.5% to 24.9% among practices. Regression analysis indicated a positive and significant correlation between rates based on the data generated by the 2 different approaches (r2 = 0.50).

Question: Can you use a sequential sample of patients as a substitute for a full practice audit?

A rate of mammography screening based on a sequential sample can reasonably approximate the actual rate of mammography screening that would be found based on a full practice audit.

Answer the question based on the following context: Psychological factors may be important determinants of adherence to antihypertensive medication, as they have been repeatedly found to be associated with an increased risk of hypertension, coronary heart disease, and health-damaging behaviours. We examined the importance of several psychological attributes (sense of coherence, optimism, pessimism, hostility, anxiety) with regard to antihypertensive medication adherence assessed by pharmacy refill records. A total of 1021 hypertensive participants, aged 26-63 years, who were employees in eight towns and 12 hospitals in Finland were included in the analyses. We found 60% of patients to be totally adherent, 36% partially adherent, and 4% totally nonadherent. Multinomial regression analyses revealed high sense of coherence to be associated with lower odds of being totally nonadherent in contrast of being totally adherent (odds ratio=0.55; 95% confidence interval: 0.31-0.96). This association was independent of factors that influenced adherence to antihypertensive medication, such as sociodemographic characteristics, health-related behaviours, self-reported medical history of doctor-diagnosed comorbidity, and anteriority of hypertension status. The association was not specific to certain types of antihypertensive drugs.

Question: Do psychological attributes matter for adherence to antihypertensive medication?

High sense of coherence may influence antihypertensive medication-adherence behaviour. Aspects characterizing this psychological attribute, such as knowledge (comprehensibility), capacity (manageability), and motivation (meaningfulness) may be important determinants of adherence behaviour for asymptomatic illnesses, such as hypertension, in which patients often do not feel or perceive the immediate consequences of skipping medication doses.

Answer the question based on the following context: The inability to provide effective postoperative analgesia is one of the major disadvantages of intravenous regional anesthesia (IVRA). We designed a prospective, randomized, double blind study to evaluate the analgesic effectiveness of adding both ketorolac and dexamethasone to lidocaine for IVRA. The study involved 45 patients undergoing ambulatory hand surgery. They were randomly allocated into three groups: Group L, Group LK and Group LDK. Group L received 3 mg x kg-1 lidocaine; Group LK received 3 mg x kg-1 lidocaine + 30 mg ketorolac; and Group LDK received 3 mg x kg-1 lidocaine for IVRA + 8 mg dexamethasone + 30 mg ketorolac for IVRA using a 40 mL solution. Sensory and motor block onset and recovery times were recorded. Tourniquet pain and pain at the operative site were assessed by a visual analog scale. In the first 24 h after surgery, opioid requirements and total analgesic consumption, including side effects, were noted. Sensory and motor block onset and recovery times were similar in all groups. Patients in Groups LK and LDK required less alfentanyl for control of intraoperative and early postoperative pain. Further, patients in Groups LK and LDK reported significantly lower pain scores compared to those in Group L (P<0.001). Patients in Groups LK and LDK required fewer postoperative ketorolac tablets (2.2+/-1.6 and 1.3+/-0.6 tablets, respectively) in the first 24 h after surgery and had significantly longer periods during which they required no analgesics (524 min and 566 min, respectively) compared to those in Group L (3.8+/-1.3 tablets; 122 min, P<0.001).

Question: Does the addition of ketorolac and dexamethasone to lidocaine intravenous regional anesthesia improve postoperative analgesia and tourniquet tolerance for ambulatory hand surgery?

IVRA with lidocaine and with the inclusion of ketorolac and dexamethasone provides effective perioperative analgesia for patients undergoing ambulatory hand surgery, when compared to the use of lidocaine alone or lidocaine with ketorolac IVRA.

Answer the question based on the following context: It was reported by several groups that patients diagnosed as primary antiphospholipid syndrome (PAPS) had developed a full-blown systemic lupus erythematosus (SLE) even after many years of follow-up. Little is known about clinical and/or serological factors that may help predict such evolution. Antinucleosome antibodies (anti-NCS) were described to appear in early stages of SLE, in particular before anti-dsDNA antibodies. The aim of the study is to evaluate the prevalence of anti-NCS in a large cohort of PAPS patients. IgG and IgM anti-NCS antibodies were detected using a home made assay with H1-stripped chromatin as antigen. Sera from 106 PAPS patients were tested; 52 of them were also tested during the follow-up, at least 2 years apart form the basal sample. Medium-high titre anti-NCS were found in nearly half of the patients (49/106, 46%), more frequently in those presenting features of "lupus like disease". Most of patients displayed an unchanged pattern of anti-NCS over time. We describe three cases of PAPS patients that developed SLE after many years of follow-up; high titre and low titre anti-NCS were present in two and one of them respectively several years before evolving into SLE.

Question: Primary antiphospholipid syndrome evolving into systemic lupus erythematosus: may antinucleosome antibodies be predictive?

A significant proportion of PAPS patients displayed medium-high titre anti-NCS, suggesting that the autoimmune response against chromatin may be a relevant event not only in patients with SLE. Further studies are warranted to explore the predictive value of anti-NCS with respect to the evolution from PAPS to SLE.

Answer the question based on the following context: Mesh reinforcement in hiatal hernia surgery is debated. Randomized controlled trials have shown that recurrences may be reduced, but there is also the fear of mesh-related complications. Experimental studies on the characteristics of specific mesh types with regard to the risk of such complications are rare. The current study aimed to investigate the properties of a circular heavy-weight polypropylene mesh in terms of stenosis, migration, erosions, and adhesions in a porcine model. A 55 x 55-mm heavy-weight polypropylene mesh with a 16.5-mm eccentric hole for the esophagus corresponding to a calculated mesh area of 2811 mm(2) and a hole area of 214 mm(2) were implanted in nine German Landrace pigs. Six weeks later, the meshes were explanted and investigated for size, shrinkage, migration and adhesions. The total mesh area shrank to a mean of 2,040 +/- 178 mm(2) (p<0.001), and the hole for the esophagus showed a trend toward an increase to 239 +/- 38 mm(2) (p = 0.108). In not a single location did the mesh overhang the hiatal margin. The mean distance of retraction from the hiatal margin was 4.3 +/- 2.8 mm. Therefore, no stenoses, migrations, or erosions occurred.

Question: Is a circular polypropylene mesh appropriate for application at the esophageal hiatus?

A circular heavy-weight polypropylene mesh seems to be appropriate for the application at the esophageal hiatus in terms of safety and stability. This means that it is characterized by a position-stable centered fixation around the esophagus without a tendency toward stenosis, migration, or erosion.

Answer the question based on the following context: When a palpable breast mass is detected, a biopsy is usually performed even if the mass reveals probably benign morphologic features on imaging, as there is relatively little data reporting the outcome of such breast masses. To determine the negative predictive value for sonographic evaluation of palpable breast masses with probably benign morphology, and to assess whether follow-up may be an acceptable alternative to immediate biopsy. Of the 1399 sonograms of palpable masses from January 2004 to September 2005, there were 397 patients with masses of probably benign morphology. This study included 274 of these patients (age range 12-64 years, mean age 34 years) with 312 palpable masses that were pathologically confirmed by fine-needle aspiration (n=7), ultrasound (US)-guided core needle biopsy (n=180), or surgical biopsy (n=125). The false-negative rate, negative predictive value (NPV), and 95% confidence interval (CI) were calculated using the SPSS statistical software package for Windows, version 12.0. A P value<0.05 was considered statistically significant. Of the 312 masses, there were 310 benign lesions and two malignancies, resulting in a false-negative rate of 0.6% (NPV 99.4%, P value=0.0432, 95% CI 0.0-1.5%).

Question: Palpable breast masses with probably benign morphology at sonography: can biopsy be deferred?

The negative predictive value of sonography for palpable breast masses with probably benign morphology is high (99.4%). Therefore, short-term imaging follow-up can be an acceptable alternative to immediate biopsy, similar to the management of nonpalpable probably benign lesions (BI-RADS category 3).

Answer the question based on the following context: The faculty development community has been challenged to more rigorously assess program impact and move beyond traditional outcomes of knowledge tests and self ratings. The purpose was to (a) assess our ability to measure supervisors' feedback skills as demonstrated in a clinical setting and (b) compare the results with traditional outcome measures of faculty development interventions. A pre-post study design was used. Resident and expert ratings of supervisors' demonstrated feedback skills were compared with traditional outcomes, including a knowledge test and participant self-evaluation. Pre-post knowledge increased significantly (pre = 61%, post = 85%; p<.001) as did participant's self-evaluation scores (pre = 4.13, post = 4.79; p<.001). Participants' self-evaluations were moderately to poorly correlated with resident (pre r = .20, post r = .08) and expert ratings (pre r = .43, post r = -.52). Residents and experts would need to evaluate 110 and 200 participants, respectively, to reach significance.

Question: Assessing change in clinical teaching skills: are we up for the challenge?

It is possible to measure feedback skills in a clinical setting. Although traditional outcome measures show a significant effect, demonstrating change in teaching behaviors used in practice will require larger scale studies than typically undertaken currently.

Answer the question based on the following context: The effect of coronary revascularization on disappearance of the severe conduction disturbances is still unclear. We sought to determine whether revascularization may induce recovery of sinus rhythm in patients with significant coronary artery disease and complete atrioventricular block (AVB). Fifty-three patients who had third-degree AVB and significant coronary artery disease were enrolled. Patients with acute coronary syndromes were excluded. Thirty-three (62%) patients were men and the mean age was 65 +/- 10 y. All patients received a permanent dual-mode, dual-pacing, dual-sensing (DDD) pacemaker. Coronary disease was treated medically in 16 (30%) patients due to patient preference or ineligibility. Thirty-seven (70%) patients underwent a revascularization procedure (coronary artery bypass grafting [CABG]: 16, percutaneous coronary intervention [PCI]: 21 pts). Mean follow-up was 36 +/- 6 mo and patients were evaluated every 3 mo according to their resting electrocardiograms (ECGs) at each visit. In the medically treated group, 13 (81%) patients still had third-degree AVBs at the end of the follow-up period, while 3 (19%) patients returned to normal sinus rhythm. On the other hand, 27 out of 37 patients (73%) who were revascularized were still in complete AVB, and 10 patients from this group (27%) had returned to normal sinus rhythm. There was no statistically significant difference between the revascularized and medically treated groups in terms of need for a pacemaker.

Question: Should we revascularize before implanting a pacemaker?

Patients who have concomitant severe conduction disturbances and significant coronary disease may well receive a pacemaker before a revascularization procedure. Our data shows that coronary revascularization has little, if any, impact on returning to normal AV conduction.

Answer the question based on the following context: RT-PCR, Western blotting, and immuno-histochemistry were performed to determine the expression pattern of transcription factor PDX-1 in primary colorectal tumor, hepatic metastasis, and benign colon tissue from a single patient. The highest PDX-1 transcription levels were detected in the metastasis material. Lower levels of PDX-1 were found to be present in the primary tumor, while normal colon tissue failed to express detectable levels of PDX-1. Western blot data revealed a PDX-1 expression pattern identical to that of mRNA expression. Immunohistochemistry confirmed high metastasis PDX-1 expression, lower levels in the primary tumor, and the presence of only traces of PDX-1 in normal colon tissue.

Question: Transcription factor PDX-1 in human colorectal adenocarcinoma: a potential tumor marker?

These data argue for further evaluation of PDX-1 as a biomarker for colorectal cancer.

Answer the question based on the following context: To determine the efficacy of intravenous aminophylline in the treatment of adult patients hospitalized for exacerbation of asthma. Randomized, double-blind, placebo-controlled trial throughout the study. University Hospital Clinical Research Center. Forty-four patients admitted from the emergency room with a primary diagnosis asthma; 39 patients completed the study. Patients received either intravenous aminophylline or placebo in addition to frequent nebulized albuterol; prednisone 0.5 mg/kg body weight every 6 h orally; and supplemental oxygen. Aminophylline infusion rates were adjusted to achieve serum theophylline concentrations of 10 to 20 micrograms/ml. Changes were made in placebo infusion rates to maintain the double blind design. Forced expiratory volume in 1 s (FEV1) and other spirometric measurements every 8 h by a blinded investigator or trained respiratory therapist. Subjective patient response and duration of hospitalization were compared. No difference in spirometric measurements was observed between the two groups at any time point. On admission to the study, FEV1 in the placebo group was 41.5 (+/- 2.9) percent predicted and in the aminophylline group 34.7 (+/- 2.3) percent predicted (p = 0.08). At discharge, FEV1 was 70.4 (+/- 2.9) percent predicted in the placebo group and 63.7 (+/- 2.8) percent predicted in the theophylline group (p = 0.10). There was no difference in subjective patient rating or duration of hospitalization between the two groups (placebo 1.95 days and aminophylline 1.78 days, p = 0.51).

Question: Inhaled albuterol and oral prednisone therapy in hospitalized adult asthmatics. Does aminophylline add any benefit?

Our results suggest that aminophylline therapy does not add significant benefit to other standard therapies in hospitalized adult asthmatic patients. Because of the risks and cost of aminophylline treatment in the hospital setting, further research is needed to determine if there are subgroups of adult asthmatics who may benefit from the addition of aminophylline to other standard optimal therapies.

Answer the question based on the following context: To see whether a prepregnancy clinic for diabetic women can achieve tight glycaemic control in early pregnancy and so reduce the high incidence of major congenital malformation that occurs in the infants of these women. An analysis of diabetic control in early pregnancy including a record of severe hypoglycaemic episodes in relation to the occurrence of major congenital malformation among the infants. A diabetic clinic and a combined diabetic and antenatal clinic of a teaching hospital. 143 Insulin dependent women attending a prepregnancy clinic and 96 insulin dependent women managed over the same period who had not received specific prepregnancy care. The incidence of major congenital malformation. Compared with the women who were not given specific prepregnancy care the group who attended the prepregnancy clinic had a lower haemoglobin AI concentration in the first trimester (8.4% v 10.5%), a higher incidence of hypoglycaemia in early pregnancy (38/143 women v 8/96), and fewer infants with congenital abnormalities (2/143 v 10/96; relative risk among women not given specific prepregnancy care 7.4 (95% confidence interval 1.7 to 33.2].

Question: Can prepregnancy care of diabetic women reduce the risk of abnormal babies?

Tight control of the maternal blood glucose concentration in the early weeks of pregnancy can be achieved by the prepregnancy clinic approach and is associated with a highly significant reduction in the risk of serious congenital abnormalities in the offspring. Hypoglycaemic episodes do not seem to lead to fetal malformation even when they occur during the period of organogenesis.

Answer the question based on the following context: To examine the possible use of readmission rates as an outcome indicator of hospital inpatient care by investigating avoidability of unplanned readmissions within 28 days of discharge. Retrospective analysis of a stratified random sample of case notes of patients with an unplanned readmission between July 1987 and June 1988 by nine clinical assessors (263 assessments) and categorisation of the readmission as avoidable, unavoidable, or unclassifiable. District in North East Thames region. 481 General medical, geriatric, and general surgical inpatients with a readmission at 0-6 days or 21-27 days after the first (index) discharge between July 1987 and June 1988 from whom 100 case notes were selected randomly and of which 74 were available for study. Assessment of readmissions as avoidable, unavoidable, unclassifiable, variability of assessment within cases and variability among assessors according to specialty and duration to readmission. General medical and geriatric readmissions and surgical readmissions at 0-6 days after discharge were more likely to be assessed as avoidable than those at 21-27 days (medical readmissions 32 v 6%, surgical admissions 49 v 19%). General surgical readmissions were significantly more frequently assessed as avoidable than general medical and geriatric readmissions. The extent of agreement between doctors varied, with general medical and geriatric readmissions at 21-27 days after first discharge causing the greatest variability of judgment.

Question: Are readmissions avoidable?

Differences were apparent in the extent of avoidability of readmissions in different groups of admissions. However, assessors rated only 49.3% of the group with the highest proportion of avoidable admissions (surgical readmissions at 0-6 days) as avoidable. The remainder were thought to be unavoidable except for 2%, which could not be classified. The use of readmission rates as an outcome indicator of hospital inpatient care should be avoided.

Answer the question based on the following context: A retrospective study of abdominal CT scans of patients with proved intraabdominal desmoid tumors was done to determine if any objective characteristics exist to differentiate desmoids related to Gardner's syndrome from isolated desmoids. Because the desmoid tumors of Gardner's syndrome can predate the diagnosis of Gardner's syndrome, it would be helpful to know which patients with desmoids need careful follow-up studies as well as initial workup for Gardner's syndrome and all its ramifications. Also, it would be important to differentiate benign from malignant desmoids associated with Gardner's syndrome. It was hoped that the location, enhancement characteristics, and/or the presence or absence of infiltration might be of value. We were interested in noting if, over time, the growth characteristics of desmoids found in Gardner's syndrome were different from those of isolated desmoids. We reviewed 101 abdominal CT scans obtained in 23 patients during a 13-year period. Forty desmoid tumors were intraabdominal, including 30 lesions associated with Gardner's syndrome in 13 patients and 10 desmoids of the idiopathic form in 10 patients. These tumors were studied to define location; whether they were single or multiple; and whether they had any specific CT characteristics regarding margins, attenuation numbers, or contrast enhancement. Desmoid tumors associated with Gardner's syndrome were more likely to be multiple (38%, five of 13 patients) and to involve the mesentery (60%, 18 of 30 tumors) and the abdominal wall (40%, 12 of 30 tumors), whereas isolated desmoid tumors were singular (all 10 patients) and were located in the retroperitoneum (six cases), pelvis (three), and anterior wall (one). Desmoids related to Gardner's syndrome also tended to be smaller (mean diameter, 4.8 cm) than idiopathic desmoids (mean diameter, 13.8 cm). No differentiating CT characteristics regarding margins, attenuation numbers, or response to contrast material were ascertained. Ten new lesions (seven intraabdominal, three mesenteric) developed in three patients with Gardner's syndrome, whereas no new intraabdominal lesions developed in patients with idiopathic desmoids. Follow-up data on 16 surgically resected desmoids in nine patients (seven with Gardner's syndrome and two with isolated desmoids) revealed seven local recurrences (two in the two patients with isolated desmoids and five in two patients with Gardner's syndrome).

Question: CT of intraabdominal desmoid tumors: is the tumor different in patients with Gardner's disease?

No CT characteristics, such as attenuation values, margins, and response to the contrast material, were found that would enable differentiation between isolated intraabdominal desmoids and those associated with Gardner's disease. Desmoid tumors associated with Gardner's syndrome tend to occur in the mesentery and abdominal wall, whereas isolated desmoids involve the retroperitoneum and pelvis. When studying CT scans obtained over time, new lesions were noted to develop in a few of the patients with Gardner's syndrome (three of 13), whereas no new lesions were found in patients with isolated desmoids.

Answer the question based on the following context: The role of CT grading of blunt splenic injuries is still controversial. We studied the CT scans of adult patients with proved blunt splenic injuries to determine if the findings accurately reflect the extent of the injury. We were specifically interested in establishing if CT findings can be used to determine whether patients require surgery or can be managed conservatively. The CT scans of 45 patients with blunt splenic injuries were analyzed retrospectively, and the CT findings were correlated with the need for surgery. We used (1) a CT scale (I-V) for splenic parenchymal injuries that also allowed a comparison with the surgical findings in patients who underwent laparotomy, and (2) a CT-based score (1-6) that referred to both the extent of parenchymal injuries and the degree of hemoperitoneum. Early laparotomy was done in nine patients. Conservative treatment was attempted in 36 patients and was successful in 31; five patients needed delayed laparotomy after attempted conservative treatment. According to the CT scale (I-V), 25 patients had injuries of grade I or II; 20 patients were successfully treated conservatively, whereas five patients needed delayed surgery. Nineteen patients had injuries of grade III, IV, or V; eight patients underwent early laparotomy, and 11 patients were successfully treated conservatively. CT findings were false-negative in one patient who underwent early surgery for diaphragmatic rupture. A comparison of the CT findings with the intraoperative findings according to the CT scale (I-V) revealed identical parenchymal injury grades in four cases, whereas the injuries were underestimated on CT scans in four patients and overestimated on CT scans in six patients. The CT-based score (1-6) was applied to 41 patients; four patients who had peritoneal lavage before CT were excluded. Twelve patients had scores below 2.5; 10 patients were successfully treated conservatively, and two patients needed delayed surgery. Twenty-nine patients had scores of 2.5 or higher; six patients underwent early laparotomy, 20 patients were successfully treated conservatively, and three patients needed delayed surgery. Patients who required delayed surgery had a mean score of 3.0 (SD, +/- 1.0), which was similar to those who did not require surgery (3.1 +/- 1.5; p = .45).

Question: Blunt splenic trauma in adults: can CT findings be used to determine the need for surgery?

Our results show that CT findings cannot be used to determine reliably which patients require surgery and which patients can be treated conservatively. Even patients with splenic parenchymal injuries of CT grade III, IV, and V and with CT-based scores of 2.5 or higher can be successfully treated conservatively if the clinical situation is appropriate, whereas delayed splenic rupture can still develop in patients with low CT grades or scores. The choice between operative and nonoperative management of splenic trauma should be mainly based on clinical findings rather than CT findings.

Answer the question based on the following context: Mivacurium's rapid onset and short duration of action in children suggests that intramuscular administration might treat laryngospasm and facilitate tracheal intubation without producing prolonged paralysis. Accordingly, the authors measured the neuromuscular effects of intramuscular mivacurium in anesthetized infants and children. Twenty unpremedicated infants and children (3 months to 5 yr of age) were anesthetized with nitrous oxide and halothane and permitted to breathe spontaneously. When anesthetic conditions were stable, mivacurium was injected into the quadriceps or deltoid muscle. Minute ventilation and adductor pollicis twitch tension were measured. The initial mivacurium dose was 250 micrograms/kg and was increased (to a maximum of 800 micrograms/kg, at which dose the trial was ended) or decreased according to the response of the previous patient, the goal being to bracket the dose producing 80-90% twitch depression within 5 min of drug administration. No patient achieved>80% twitch depression within 5 min of mivacurium administration. Peak twitch depression was 90 +/- 13% (mean +/- SD) for infants and 88 +/- 15% for children at 15.0 +/- 4.6 min and 18.4 +/- 6.4 min, respectively. Ventilatory depression (a 50% decrease in minute ventilation or a 10-mmHg increase in end-tidal carbon dioxide tension) occurred at 9.0 +/- 4.4 min in nine infants and 13.6 +/- 7.5 min in 10 children; ventilatory depression did not develop in one infant given a dose of 350 micrograms/kg. Time to peak twitch depression or ventilatory depression was not faster with larger doses.

Question: Is intramuscular mivacurium an alternative to intramuscular succinylcholine?

Although ventilatory depression preceded twitch depression, both occurred later with intramuscular mivacurium than would be expected after intravenous mivacurium or intramuscular succinylcholine. The authors speculate that the onset of intramuscular mivacurium is too slow to treat laryngospasm or to facilitate routine tracheal intubation in infants or children, despite administration of large doses.

Answer the question based on the following context: Halothane attenuates endothelium-dependent relaxation. To differentiate halothane's effect on endothelium-derived relaxing factor/nitric oxide (EDRF/NO) production from its effect on nitric oxide action on vascular smooth muscle, halothane's effect on endothelium-dependent relaxation was studied in a bioassay system. Indomethacin-treated, bovine aortic endothelial cells (BAEC) grown on microcarrier beads, continuously perfused by oxygenated and carbonated (95% O2, 5% CO2) Krebs-Ringer solution served as nitric oxide donors while an isolated denuded rabbit aortic ring directly superfused by the effluent of the BAEC and precontracted with phenylephrine was used to detect EDRF/NO release. The effect of basal and bradykinin-stimulated EDRF release on the tension of the vascular ring was measured. In the bioassay, it was possible to treat either the vascular denuded ring alone or the vascular ring plus the BAEC with halothane by adding it to the perfusate either upstream or downstream from the BAEC. Halothane (final concentration 2.2%) was added to the perfusate at these two positions, and its effect on the relaxation induced by EDRF/NO was determined. In some experiments, the preparations were treated with hemoglobin or L-monomethyl-L-arginine to attenuate the relaxation induced by the EDRF/NO pathway. Finally, halothane's effect on vascular relaxation induced by an increasing concentration of sodium nitroprusside was measured. Halothane's concentration in the perfusate was determined by gas chromatography using electron capture for anesthetic measurement. EDRF/NO released by the BAEC was responsible for the relaxation of the vascular ring. Halothane added to the perfusate potentiated the tension induced by phenylephrine (7.1 +/- 1.89%) and attenuated the relaxation induced by the release of EDRF/NO. This effect was reversible after discontinuation of halothane. Halothane's effect was present even when the anesthetic was added to the perfusate downstream to the perfusion of the endothelial cells. Halothane had no effect on the vascular relaxation induced by sodium nitroprusside.

Question: Does halothane interfere with the release, action, or stability of endothelium-derived relaxing factor/nitric oxide?

The authors' data demonstrate that halothane does not interfere with endothelial cell release of EDRF/NO and its smooth muscle cell relaxation but seems to modify either EDRF/NO half-life or its activated redox form.

Answer the question based on the following context: To evaluate the relationship between three types of cataract or cataract surgery and age-related maculopathy. Population-based prevalence study. A total of 4926 people participating in The Beaver Dam Eye Study from 1988 through 1990. Grading of photographs for nuclear sclerosis, cortical cataract, and posterior subcapsular cataract and signs of age-related maculopathy was performed using standardized protocols. After adjusting for other risk factors, nuclear sclerosis was associated with increased odds of early age-related maculopathy (odds ratio [OR], 1.96; 95% confidence interval [CI], 1.28 to 3.01) but not of late age-related maculopathy (OR, 1.38; 95% CI, 0.52 to 3.63). Neither cortical nor posterior subcapsular cataracts were related to age-related maculopathy. There were increased odds of early age-related maculopathy in eyes that had undergone cataract surgery.

Question: Is age-related maculopathy associated with cataracts?

These data suggest a possible commonly shared pathogenesis between nuclear sclerotic cataract and age-related maculopathy.

Answer the question based on the following context: The relationships between fasting plasma levels of retinol, ascorbic acid, alpha-tochopherol, and beta-carotene and age-related macular degeneration (AMD) were studied in a population enrolled in the Baltimore Longitudinal Study of Aging (BLSA), in which most of the data were collected 2 or more years before assessment of macular status. A total of 976 participants in the study were scheduled for a biennial examination from January 1988 through January 1, 1990, which included taking lens and macular photographs. A total of 827 (85%) of the participants had fundus photographs taken, and most plasma data were available for 82% of those subjects with fundus photographs. Age-related macular degeneration was defined as neovascular changes, geographic and nongeographic atrophy, large or confluent drusen, or hyperpigmentation. A total of 226 cases of AMD were available for analysis. Logistic regression analyses suggested that alpha-tocopherol was associated with a protective effect for AMD, adjusted for age, sex, and nuclear opacity. An antioxidant index, including ascorbic acid, alpha-tocopherol, and beta-carotene, was also protective for AMD. Our conclusions must be tempered with the knowledge that the population under study was basically well nourished, and few individuals had any clinically deficient status. The study cannot exclude the possibility that quite low levels of micronutrients, lower than those observed in this study, might be risk factors for AMD.

Question: Are antioxidants or supplements protective for age-related macular degeneration?

The data suggest a protective effect for AMD of high plasma values of alpha-tocopherol. An antioxidant index, composed of plasma ascorbic acid, alpha-tocopherol, and beta-carotene, was also protective. The use of vitamin supplements to prevent AMD is not supported by these data, which showed no protective effect of vitamin use.

Answer the question based on the following context: To evaluate specified biomedical, socio-economic, and psychosocial criteria as predictors of therapeutic success to optimize patient selection for continuous ambulatory peritoneal dialysis (CAPD) in a developing country. A retrospective cohort study investigating the relationship between episodes of peritonitis and exitsite infection, and predetermined biomedical, socioeconomic, and psychosocial data. A CAPD unit in a large tertiary care teaching hospital. All 132 patients entering the CAPD program between 1987 and 1991. Overall mean survival time on CAPD was 17.3 months. Peritonitis rates were high, especially among blacks. Multivariate analysis demonstrated that increased peritonitis rates were associated with age, black race, diabetes, and strongly so with several psychosocial factors. Because being black was strongly linked to poor socioeconomic conditions, repeat analysis excluding blacks showed the same associations with the above variables, but, additionally, several socioeconomic factors were associated with high peritonitis rates. No significant explanatory variables were shown for exit-site infections.

Question: Continuous ambulatory peritoneal dialysis: an option in the developing world?

The association of biomedical, socioeconomic, and psychosocial variables with high peritonitis rates has important implications for the selection of patients for CAPD in this setting.

Answer the question based on the following context: To describe the form of midwifery practice preferred by physicians practising obstetrics, nurses providing maternity care and midwives. Mail survey conducted in 1991. Province of Quebec. A systematic random sample of 844 physicians, 808 nurses and 92 midwives; 597, 723 and 92 respectively completed the questionnaire, for an overall response rate of 80%. Midwife training options, range of responsibilities, location of midwifery care, relationship to other maternity care providers and degree of autonomy. Most of the physicians, nurses and midwives surveyed agreed that if midwifery was legalized, midwives should have a university degree, provide basic care to women with normal pregnancy and delivery, provide prenatal and postnatal care in hospitals and community health centres, perform delivery in hospitals and work in close collaboration with the other maternity care professionals. Disagreement existed concerning the level of university training required, the need for training in nursing first, the scope of medical intervention performed by midwives, out-of-hospital delivery, the autonomy of midwives and control over their practice.

Question: Midwifery defined by physicians, nurses and midwives: the birth of a consensus?

Some consensus on midwifery practice exists between physicians, nurses and midwives. In jurisdictions where opposition to midwives is strong, such consensus could serve as the starting point for the introduction of midwifery.

Answer the question based on the following context: Disseminated intravascular coagulation (DIC) is usually diagnosed in sick infants who have prolonged clotting times, depletion of platelets and coagulation factors, and elevated levels of fibrin derivatives. However, the diagnostic accuracy of abnormal coagulation profiles in neonates at risk of DIC has been uncertain. Since DIC is characterized by activation of both the coagulation and fibrinolytic systems, the objective of this study was to determine whether coagulation screening tests correctly identify infants with biochemical evidence of increased thrombin and plasmin generation. Non-surgical patients in a tertiary care nursery who were sick enough to require an indwelling arterial catheter for monitoring purposes, were enrolled in a prospective cohort study. Blood samples for thrombin/antithrombin III (TAT) complexes and the plasmin-derived fibrinopeptide B beta 1-42 were drawn 36 to 72 h after birth from a free-flowing arterial line. Platelet counts, D-Dimer levels, plasma fibrinogen concentrations and prothrombin times, expressed as International Normalized Ratios or INR, were measured at the same time. One hundred patients were studied. Fifty-seven infants had elevated levels of TAT (>or = 4 micrograms/l) and B beta 1-42 (>or = 4 nmol/l). The sensitivities of platelets<150 x 10(9)/l, D-Dimer>500 ng/ml, fibrinogen<1.5 g/l, and INR>1.5 were 39%, 30%, 12%, and 11%, respectively. Corresponding specificities were 88%, 91%, 98%, and 95%.

Question: Do coagulation screening tests detect increased generation of thrombin and plasmin in sick newborn infants?

Abnormal coagulation screens in sick newborn infants strongly support a diagnosis of DIC. However, normal screens do not exclude activation of the coagulation and fibrinolytic systems.

Answer the question based on the following context: Although a number of metabolic and psychosocial factors have been identified as coronary risk factors, no studies have evaluated the relation between personality and cerebrovascular disease. The purpose of the present study was to elucidate the relation between the characteristics of anger or aggression and the severity of carotid atherosclerosis on the basis of the findings of B-mode ultrasonography. The Cornell Medical Index was used to measure anger in 34 patients with signs of atherosclerosis or at least one of four recognized risk factors for atherosclerosis (hypertension, hypercholesterolemia, diabetes mellitus, and cigarette smoking). The Rosenzweig Picture Frustration Study and Yatabe-Guilford Personality Test were used to evaluate aggression. High-resolution B-mode ultrasonography was performed, and the severity of carotid atherosclerosis was determined by plaque score. The occurrence of risk factors for carotid atherosclerosis was compared among the patients. The correlation of plaque score with one item that endorses anger was r = .65 (P<.01) and with "extrapersistive" in aggression was r = .50 (P<.01). Multivariate analysis identified significant correlations between plaque score and age, hypercholesterolemia, and anger.

Question: Do anger and aggression affect carotid atherosclerosis?

Our results suggest that anger and, perhaps, aggression may be risk factors for cerebrovascular disease.

Answer the question based on the following context: This study was designed to assess the predictability of 5 mg bupivacaine to give a T10 sensory level when injected subarachnoid in elderly patients. Sixty-five patients aged 75 years or more, scheduled to undergo elective hip surgery, participated in the study. Patients were randomized to receive either 5 mg plain bupivacaine without epinephrine (isobaric group), or 5 mg hyperbaric bupivacaine (hyperbaric group). A 19-gauge catheter was inserted at the L3-4 interspace and threaded 4 cm cephalad in the subarachnoid space. Patients were placed in supine horizontal position and sensory level was assessed every 5 minutes over 20 minutes. Increments of 2.5 mg bupivacaine were given when sensory level did not reach T10 at the 20th minute. After 20 minutes, the mean sensory level was T8.8 +/- 3.2 in the isobaric group and T7.2 +/- 4.3 in the hyperbaric group without significant difference. Hypotension, defined as greater than a 25% drop in mean arterial pressure, was not significantly different in the two groups: 37.5% and 42.4%, respectively. However, patients who developed hypotension were older (84.3 +/- 7.8 years) than the others (80.3 +/- 5.9 years), and cephalad spread of sensory anesthesia was higher in patients who developed a hypotension (T5.3 +/- 1.4 versus T9.5 +/- 4). In each group, sensory levels did not reach T10 in five patients after initial dose. Five had a sensory block that was too low in spite of incremental doses with the patient in the horizontal position. For the last three, an unintentional sacral placement of the catheter was proved radiologically.

Question: Continuous spinal anesthesia: does low-dose plain or hyperbaric bupivacaine allow the performance of hip surgery in the elderly?

The authors conclude that 5 mg bupivacaine is too high a dose in the elderly to limit the sensory blockade at T10 and avoid hypotension. In elderly patients, this dose allowed surgery to be performed, provided that the sensory level reached T10. When the initial dose only affects lumbar dermatomes, a caudal direction of the catheter must be evoked, and changing position must be preferred to incremental injections to reach thoracic levels.

Answer the question based on the following context: The aim was to determine whether the antiarrhythmic effects of preconditioning are modified by blockade of K+ATP channels with glibenclamide in a model (anaesthetised dogs) in which this procedure has previously been shown to prevent the effects of preconditioning in reducing myocardial infarct size. 10 mongrel dogs were preconditioned by two 5 min occlusions of the left anterior descending coronary artery, separated by a 20 min reperfusion period, and then subjected, 20 min later, to a prolonged (25 min) occlusion and to subsequent reperfusion. In another 10 dogs glibenclamide (300 micrograms.kg-1) was given by intravenous injection both after the first preconditioning stimulus and before the prolonged occlusion. Control dogs (25) were subjected to a 25 min occlusion followed by reperfusion; five of these dogs also received glibenclamide. Preconditioning reduced the severity of ventricular arrhythmias, epicardial ST segment elevation, and the degree of inhomogeneity of conduction. The antiarrhythmic effect of preconditioning was attenuated by glibenclamide (twice as many ventricular premature beats and more episodes of ventricular tachycardia) but there was no modification of preconditioning induced reduction in ventricular fibrillation either during ischaemia or during reperfusion, or on survival (0% in controls; 50% in preconditioned dogs with or without glibenclamide). Glibenclamide did, however, prevent the effects of preconditioning on the inhomogeneity of conduction and, less markedly, on epicardial ST segment elevation.

Question: Are ATP sensitive potassium channels involved in the pronounced antiarrhythmic effects of preconditioning?

In a similar model to that in which it has previously been shown that glibenclamide prevents the effect of preconditioning in reducing myocardial infarct size (suggesting involvement of K+ATP channels), the most pronounced antiarrhythmic effects of preconditioning (reduction in ventricular fibrillation; increase in survival) were not modified by glibenclamide. This, and other evidence, suggests that the mechanisms of the protective effect of preconditioning in reducing the severity of arrhythmias and on infarct size are not the same.

Answer the question based on the following context: Protected specimen brush (PSB) is considered to be one of the standard methods for the diagnosis of ventilator-associated pneumonia, but to our knowledge, intraindividual variability in results has not been reported previously. To compare the results of two PSB performed in the same subsegment on patients with suspected ICU-acquired pneumonia (IAP). Between October 1991 and April 1992, each mechanically ventilated patient with suspected IAP underwent bronchoscopy with two successive PSB in the lung segment identified as abnormal on radiographs. Results of the two PSB cultures were compared using 10(3) cfu/ml cutoff for a positive result. Four definite diagnoses were established during the follow up: definite pneumonia, probable pneumonia, excluded pneumonia, and uncertain pneumonia. Forty-two episodes in 26 patients were studied; 60 percent of patients received prior antibiotic therapy. Thirty-two microorganisms were isolated from 24 pairs of PSB. Definite diagnosis was definite pneumonia in 7, probable pneumonia in 8, excluded pneumonia in 17, and uncertain pneumonia in 10 cases. The PSB recovered the same microorganisms and argued for a good qualitative reproducibility. The distinction of positive and negative results on the basis of the 10(3) cfu/ml classic threshold was less reproducible. For 24 percent of the microorganisms recovered and in 16.7 percent of episodes of suspected IAP, the two consecutive samples gave results spread out on each side of the 10(3) cfu/ml cutoff. Discordance was higher when definite diagnosis was certain or probable than when diagnosis was excluded (p = 0.015). There was no statistical effect of the order of samples between the two specimens for bacterial index and microorganism concentrations.

Question: Is protected specimen brush a reproducible method to diagnose ICU-acquired pneumonia?

These findings argue for the poor repeatability of PSB in suspected IAP and question the yield of the 10(3) cfu/ml threshold. In attempting to diagnose IAP, the results of PSB must be interpreted with caution considering the intraindividual variability.

Answer the question based on the following context: To determine differences in incidence and case fatality of stroke in district health authorities with differing standardised mortality ratios (SMR) for stroke in residents aged under 65 years in whom death from stroke is considered 'avoidable'. Registration of first ever strokes in three district health authorities. Patients were assessed and followed up over one year by one of three observers. West Lambeth, Lewisham and North Southwark, and Tunbridge Wells District Health Authorities in south east England. Patients under the age of 75 years having a first ever in a lifetime stroke between 15 August 1989 and 14 August 1990. Age specific incidence rates and survival time from stroke to death. Severity was assessed in terms of the level of consciousness and the presence of speech, urinary, and motor impairment within the first 24 hours of the stroke. Altogether 386 strokes were registered. There was a significant difference in the incidence rate between district health authorities in those aged under 65 (p<0.01). The overall case fatality was 26% at three weeks with no significant difference between the districts. Poor survival was associated jointly with increased age and with coma, incontinence, and swallowing impairment in the first 24 hours after a stroke.

Question: Does the incidence, severity, or case fatality of stroke vary in southern England?

The SMRs for stroke in those aged under 65 in these three health districts reflect the incidence of stroke. Case fatality at three weeks does not vary between these districts and consequently would not be a sensitive indicator of the quality of care. This also suggests that differences in services between the districts did not lead to changes in prognosis. In districts with high SMRs for stroke there is a need for further study and reduction of risk factors, thereby reducing the incidence and burden of stroke locally. This study provides a framework for assessing the needs for stroke prevention and treatment in both rural and urban areas without an elaborate protocol and detailed neurological assessment.

Answer the question based on the following context: There is extensive evidence that major depression, and particularly melancholia, is characterized by hypothalamic-pituitary-adrenal (HPA) axis hyperactivity as well as systemic immune activation, which may be accompanied by increased interleukin-1 beta production. Interleukin-1 beta is known to enhance HPA axis activity during an immune response. This study investigated whether interleukin-1 beta production is related to HPA axis activity in depressed subjects. The subjects were 28 inpatients with major or minor depression and 10 normal comparison subjects. The authors measured 1) the subjects' cortisol levels after an overnight 1-mg dexamethasone suppression test (DST) and 2) mitogen-stimulated supernatant interleukin-1 beta production by peripheral blood mononuclear cells. Statistically significant positive correlations between interleukin-1 beta production and post-DST cortisol values were found in the study group as a whole and in the depressed and normal subgroups separately.

Question: Interleukin-1 beta: a putative mediator of HPA axis hyperactivity in major depression?

It is suggested that constituents of the immune response (such as interleukin-1 beta) in major depression may contribute to HPA axis hyperfunction in that illness.

Answer the question based on the following context: To characterize the etiologic agent (WA1) of the first reported case of babesiosis acquired in Washington State. Case report, and serologic, molecular, and epizootiologic studies. South-central Washington State. A 41-year-old immunocompetent man with an intact spleen who developed a moderately severe case of babesiosis. Serum specimens from the patient were assayed by indirect immunofluorescent antibody (IFA) testing for reactivity with seven Babesia species and with WA1, which was propagated in hamsters inoculated with his blood. A Babesia-specific, ribosomal-DNA (rDNA) probe was hybridized to Southern blots of restriction-endonuclease-digested preparations of DNA from WA1, Babesia microti, and Babesia gibsoni. Serum specimens from 83 family members and neighbors were assayed for IFA reactivity with WA1 and B. microti. Small mammals and ticks were examined for Babesia infection. The patient's serum had very strong IFA reactivity with WA1, strong reactivity with B. gibsoni (which infects dogs), but only weak reactivity with B. microti. DNA hybridization patterns with the rDNA probe clearly differentiated WA1 from B. gibsoni and B. microti. Four of the patient's neighbors had IFA titers to WA1 of 256. The tick vector and animal reservoir of WA1 have not yet been identified, despite trapping 83 mammals and collecting 235 ticks.

Question: Babesiosis in Washington State: a new species of Babesia?

WA1 is morphologically indistinguishable but antigenically and genotypically distinct from B. microti. Some patients elsewhere who were assumed to have been infected with B. microti may have been infected with WA1. Improved serodiagnostic and molecular techniques are needed for characterizing Babesia species and elucidating the epidemiology of babesiosis, an emergent zoonosis.

Answer the question based on the following context: Emphasis on ensuring women's access to preventive health services has increased over the past decade. Relatively little attention has been paid to whether the sex of the physician affects the rates of cancer screening among women. We examined differences between male and female physicians in the frequency of screening mammograms and Pap smears among women patients enrolled in a large Midwestern health plan. We identified claims for mammography and Pap tests submitted by primary care physicians for 97,962 women, 18 to 75 years of age, who were enrolled in the health plan in 1990. The sex of the physician was manually coded, and the physician's age was obtained from the state licensing board. After identifying a principal physician for each woman, we calculated the frequency of mammography and Pap smears for each physician, using the number of women in his or her practice during 1990 as the denominator. Using unconditional logistic regression, we also calculated the odds ratio of having a Pap smear or mammogram for women patients with female physicians as compared with those with male physicians, controlling for the physician's and the patient's age. Crude rates for Pap smears and mammography were higher for the patients of female than male physicians in most age groups of physicians. The largest differences between female and male physicians were in the rates of Pap smears among the youngest physicians. For the subgroup of women enrolled in the health plan for a year who saw only one physician, after adjustment for the patient's age and the physician's age and specialty, the odds ratio for having a Pap smear was 1.99 (95 percent confidence interval, 1.72 to 2.30) for the patients of female physicians as compared with those of male physicians. For women 40 years old and older, the odds ratio for having a mammogram was 1.41 (95 percent confidence interval, 1.22 to 1.63). For both Pap smears and mammography, the differences between female and male physicians in screening rates were much more pronounced in internal medicine and family practice than in obstetrics and gynecology.

Question: Preventive care for women. Does the sex of the physician matter?

Women are more likely to undergo screening with Pap smears and mammograms if they see female rather than male physicians, particularly if the physician is an internist or family practitioner.

Answer the question based on the following context: In 1989 the United States Public Health Service Expert Panel on the Content of Prenatal Care reported that health education should become a more integral part of prenatal care. Key questions about providing this education have not been examined. Our study compared the type of information provided to women who sought prenatal care in a public clinic and to those who were seen in a private practice and the degree to which the patients were satisfied with the information they received. One hundred fifty-nine pregnant women (80 seen in a public clinic, 79 seen in a private practice) completed two questionnaires about 38 topics commonly cited as important during pregnancy. At the first prenatal visit, the women reported their level of interest in each of the topics. At 36 to 40 weeks' gestation the women completed a second questionnaire to assess whether information was provided for each topic and whether they had learned as much as desired. Overall, the women in the public sector received more information than did the women who were cared for privately. This was statistically significant at the p<0.05 level for 25 of the 38 topics. Satisfaction with information learned was highly correlated with information received during prenatal care, but, surprisingly, it was not shown to be associated with the patient's interest level at the first visit. Fewer than 50% of private patients reported having received information about such important topics as acquired immunodeficiency syndrome, sexually transmitted diseases, preterm birth prevention, family planning, and family violence.

Question: Are there differences in information given to private and public prenatal patients?

The one-on-one approach to health education in pregnancy usually used in the private setting may not facilitate addressing many topics believed to be important components of contemporary prenatal care. Providers of private prenatal care should initiate discussion of prenatal health education topics rather than relying on patient interest in requesting information. Just as public prenatal care programs have devoted significant resources to more comprehensive prenatal education, the providers in the private sector must assure that pregnant women receive the same comprehensive information. In so doing, these providers can help promote an optimal outcome for their patients, their patients' unborn children, and the family unit.

Answer the question based on the following context: To compare pregnancy outcomes in women diagnosed as having class A1 gestational diabetes with those of a group with a normal 3-hour glucose tolerance test (GTT) to assess morbidities attributable to glucose intolerance. Selective 50-g GTT identified pregnant women who received a 3-hour GTT. Over a 16-month period, 159 women were diagnosed as having class A1 gestational diabetes according to the National Diabetes Data Group criteria. During the latter 12 months of this time period, 151 women who had a normal GTT result were identified for comparison. There were statistically significant differences in age and the development of peripartum hypertension in women with class A1 gestational diabetes compared with the normal 3-hour GTT group. There were no significant differences in any neonatal outcome variable, including percent delivering large for gestational age (LGA) neonates in women with A1 diabetes compared to controls. Overall, 111 (36%) of the 310 neonates were classified as LGA, a rate more than double that in the singleton population in our hospital. Maternal weight, parity, and a history of a previous macrosomic infant were significantly associated with LGA outcome. Mean maternal weight was the same in the two GTT groups, implying an independent effect on fetal size. Obstetric interventions were not significantly different between the groups, so differences in intervention could not account for the lack of difference in outcome variables. The impact of dietary counseling in the class A1 diabetic women is also an unlikely explanation for the lack of differences in outcome. Within the normal-GTT group, women with one abnormal 3-hour value had a frequency of LGA infants similar to that of women with all normal 3-hour GTT values. These results suggest that there is a selection effect of screening for glucose intolerance that may relate more to other risk factors for LGA outcome than to glucose intolerance. Maternal obesity is an independent and more potent risk factor for large infants than is glucose intolerance.

Question: Class A1 gestational diabetes: a meaningful diagnosis?

The diagnosis of class A1 gestational diabetes is not significantly associated with obstetric and perinatal morbidities. A nondiscriminating diagnostic test undermines the validity of population screening for glucose intolerance.

Answer the question based on the following context: To test the hypothesis that grief responses do not differ between women who terminate their pregnancies for fetal anomalies and women who experience spontaneous perinatal losses. A case-control study was conducted. Twenty-three women who underwent terminations through the genetics service of a tertiary referral obstetric hospital from January 1991 to April 1992 were assessed psychiatrically 2 months after the termination. The grief responses of these women on the Perinatal Grief Scale and the Beck Depression Inventory were compared to a demographically similar group of women assessed 2 months after they experienced spontaneous perinatal loss. Differences between the groups were assessed through one-way analysis of covariance. After matching women in the two groups, it became clear that women who terminated for fetal anomalies were significantly older than women in the comparison group, and age was inversely correlated with intensity of grief. Therefore, age was covaried in comparing the grief responses of women in the two groups. Neither statistically significant nor clinically meaningful differences were found in symptomatology between the groups. By the time of assessment, four of 23 women (17%) who terminated their pregnancies were diagnosed with a major depression, and five of 23 (22%) had sought psychiatric treatment.

Question: Do women grieve after terminating pregnancies because of fetal anomalies?

Women who terminate pregnancies for fetal anomalies experience grief as intense as those who experience spontaneous perinatal loss, and they may require similar clinical management. Diagnosis of a fetal anomaly and subsequent termination may be associated with psychological morbidity.

Answer the question based on the following context: To explore the association between midline episiotomy and the risk of third- and fourth-degree lacerations during operative vaginal delivery with either vacuum extractor or forceps. This retrospective cohort study analyzed all operative vaginal deliveries at a university hospital in 1989 and 1990. Univariate analysis of the relationships between perineal lacerations and obstetric variables was performed. Stratified analysis using the relevant variables was used to calculate relative risk (RR) estimates. Episiotomy, birth weight, and whether the index birth was the first vaginal birth were associated with third- and fourth-degree perineal lacerations. Stratified analysis demonstrated an RR of 2.4 with a 95% confidence interval of 1.7-3.5 for rectal injury with episiotomy, adjusting for parity and birth weight.

Question: Does midline episiotomy increase the risk of third- and fourth-degree lacerations in operative vaginal deliveries?

Midline episiotomy is associated with an increased risk of third- and fourth-degree perineal lacerations in operative vaginal deliveries.

Answer the question based on the following context: Angiotensin converting enzyme inhibitors, diuretics, and digoxin are each effective in treating congestive heart failure, but many patients remain symptom-limited on all three medications. This trial was designed to determine whether the addition of oral flosequinan, a new direct-acting arterial and venous vasodilator with possible dose-dependent positive inotropic effects, improves exercise tolerance and quality of life in such patients. In a randomized, double-blind multicenter trial, 322 patients with predominantly New York Heart Association class II or III congestive heart failure and left ventricular ejection fractions of 35% or less, who were stabilized on a diuretic, angiotensin converting enzyme inhibitor, and digoxin, were treated with 100 mg flosequinan once daily, 75 mg flosequinan twice daily, or matching placebo. Efficacy was evaluated with serial measurements of treadmill exercise time, responses to the Minnesota Living With Heart Failure Questionnaire (LWHF), and clinical assessments during a baseline phase and a 16-week treatment period. After 16 weeks, 100 mg flosequinan once daily produced a significant increment in median exercise time (64 seconds at 16 weeks) compared with placebo (5 seconds), whereas the higher-dose flosequinan group did not show a statistically significant increase. Flosequinan (100 mg once daily) also improved the overall LWHF score significantly compared with placebo; both active therapies decreased the physical component, but 75 mg flosequinan twice daily was associated with a trend toward worsening of the emotional component. Most clinical assessments tended to improve on active therapy.

Question: Can further benefit be achieved by adding flosequinan to patients with congestive heart failure who remain symptomatic on diuretic, digoxin, and an angiotensin converting enzyme inhibitor?

These results indicate that additional symptomatic benefit can be attained by adding flosequinan to a therapeutic regimen already including a converting enzyme inhibitor. Because in the future most patients will fall into this category, flosequinan is a potential adjunctive agent in the management of severe congestive heart failure. However, because recent evidence indicates that the flosequinan dose studied in the present trial has an adverse effect on survival, the benefit-to-risk ratio must be assessed in individual patients.

Answer the question based on the following context: In a meta-analysis of 31 placebo-controlled trials on 1356 subjects, we examined the effect of omega-3 fatty acids in fish oil on blood pressure by grouping studies that were similar in fish oil dose, length of treatment, health of the subjects, or study design. The mean reduction in blood pressure caused by fish oil for the 31 studies was -3.0/-1.5 mm Hg (95% confidence intervals: systolic blood pressure: -4.5, -1.5; diastolic blood pressure: -2.2, -0.8). There was a statistically significant dose-response effect when studies were grouped by omega-3 fatty acid dose: -1.3/-0.7 mm Hg at doses<or = 3 g/d, -2.9/-1.6 mm Hg at 3.3 to 7 g/d, and -8.1/-5.8 mm Hg at 15 g/d. Both eicosapentaenoic acid and docosahexaenoic acid were significantly related to blood pressure response. There was no effect on blood pressure in eight studies of "healthy" persons (mean reduction, -0.4/-0.7 mm Hg) at an overall mean dose of 4.2 g omega-3 fatty acids/d. By contrast, there was a significant effect of -3.4/-2.0 mm Hg in the group of hypertensive studies with a mean fish oil dose of 5.6 g/d and on systolic blood pressure only in six studies of hypercholesterolemic patients (-4.4/-1.1 mm Hg) with a mean dose of 4.0 g/d. A nonsignificant decrease in blood pressure was observed in four studies of patients with atherosclerotic cardiovascular disease (-6.3/-2.9 mm Hg). Variations in the length of treatment (from 3 to 24 weeks), type of placebo, and study design (crossover or parallel groups) did not appear to account for inconsistent findings among studies.

Question: Does fish oil lower blood pressure?

There is a dose-response effect of fish oil on blood pressure of -0.66/-0.35 mm Hg/g omega-3 fatty acids. The hypotensive effect may be strongest in hypertensive subjects and those with clinical atherosclerotic disease or hypercholesterolemia.

Answer the question based on the following context: "Preconditioning" with brief episodes of coronary artery occlusion reduces infarct size caused by subsequent sustained ischemia. However, the effects of preconditioning on the coronary vasculature are poorly understood. We sought to determine whether preconditioning would attenuate "low reflow" (ie, the deterioration in resting myocardial perfusion) and blunt the loss in coronary vasodilator reserve after sustained occlusion/reperfusion in the anesthetized open-chest canine model. Thirty-two dogs underwent 1 hour of sustained left anterior descending (LAD) coronary artery occlusion and 4 hours of reperfusion. Each dog was randomly assigned to the preconditioned group (four episodes of 5 minutes of LAD occlusion plus 5 minutes of reperfusion before sustained ischemia) or control group (no intervention). Submaximal vasodilator reserve was determined by measuring the increase in CBF in response to 0.01 mg acetylcholine (an endothelium-dependent dilator) and 0.05 mg nitroglycerin (an endothelium-independent dilator); low reflow was assessed by measurement of regional myocardial blood flow at 30 minutes and 4 hours after reflow; and infarct size was delineated by triphenyltetrazolium staining. In protocol 1 (n = 14), vasodilator reserve was measured at baseline and at 30 minutes and 4 hours after reflow. There was no change in the response to acetylcholine and nitroglycerin at 30 minutes after reperfusion compared with baseline. However, all dogs exhibited a loss in vasodilator reserve during the subsequent 3.5 hours of reflow, with no difference between control and preconditioned groups. That is, in control dogs, acetylcholine increased CBF from a baseline value of 10.1 +/- 1.3 mL/min to 18.0 +/- 2.6, 18.2 +/- 2.1, and 15.4 +/- 1.7 mL/min before occlusion, 30 minutes after reflow, and 4 hours after reperfusion, respectively (P<.05 for 30 minutes vs 4 hours after reperfusion). Similarly, in the preconditioned group, acetylcholine increased CFB from a baseline value of 12.0 +/- 2.9 mL/min to 19.6 +/- 3.8, 23.6 +/- 5.3, and 15.6 +/- 3.5 mL/min, respectively (P<.01 for 30 minutes vs 4 hours after reperfusion; P = NS between groups). In addition, all dogs exhibited low reflow, with no difference between control and preconditioned groups: subendocardial blood flow deteriorated between 30 minutes and 4 hours after reflow, from 0.91 +/- 0.20 to 0.40 +/- 0.03 mL min-1 x g-1 in control animals (P = .05 for 30 minutes vs 4 hours after reperfusion) and from 1.03 +/- 0.25 to 0.35 +/- 0.02 mL.min-1 x g-1 in the preconditioned group (P<.05 for 30 minutes vs 4 hours after reperfusion). However, all dogs in protocol 1 had small infarcts (3 +/- 1% and 2 +/- 1% of the risk region in control and preconditioned groups; P = NS), suggesting that control dogs may have been "preconditioned" by the vasodilators. An additional 18 dogs were entered into protocol 2, which was identical to protocol 1 except that acetylcholine and nitroglycerin were given only after reperfusion. In this case, we observed the expected reduction in infarct size in preconditioned dogs vs control dogs (2 +/- 1% vs 11 +/- 3% of the risk region; P<.01). However, the loss in vasodilator reserve was similar to that observed in protocol 1, with no difference between groups. Subendocardial blood flow at 30 minutes after reperfusion was higher in control animals than in preconditioned dogs (1.84 +/- 0.50 vs 0.74 +/- 0.08 mL.min-1 x g-1; P<.05), but subendocardial flow then deteriorated during the subsequent 3.5 hours to a similar value in both groups (0.55 +/- 0.11 and 0.50 +/- 0.06 mL.min-1 x g-1 in control and preconditioned dogs; P<.05 vs 30 minutes after reperfusion for both groups).

Question: Does preconditioning protect the coronary vasculature from subsequent ischemia/reperfusion injury?

The protective effects of preconditioning do not extend to the coronary vasculature in this canine model: Preconditioning neither prevented the deterioration in resting myocardial perfusion nor blunted the loss in submaximal vasodilator reserve obs

Answer the question based on the following context: To comparatively evaluate cerebral metabolic rate of oxygen consumption and a modification of it, cerebral consumption of oxygen, in patients with acute brain injury with acute anemia. Prospective, observational study. Neuroscience intensive care unit (ICU) of a university hospital. Adults (n = 62) with acute brain trauma, undergoing serial 133xenon studies of regional cerebral blood flow and global cerebral oxygen metabolism, along with other routine monitoring techniques. In 173 combined studies of blood flow and oxygen metabolism, in the presence of spontaneous decreases in hemoglobin, cerebral metabolic rate of oxygen consumption and cerebral consumption of oxygen were comparatively evaluated in three groups with different hemoglobin levels. Cerebral metabolic rate of oxygen consumption was calculated as the product of averaged regional cerebral blood flow and arterio-jugular oxygen content difference, while cerebral consumption of oxygen was calculated as the product of averaged regional cerebral blood flow and the arterio-jugular oxyhemoglobin saturation difference, i.e., cerebral extraction of oxygen. Results indicated that a decrease of hemoglobin content is paralleled by a decrease in cerebral metabolic rate of oxygen consumption, even though the level of consciousness (coma score) is essentially unchanged across three hemoglobin groups. On the other hand, cerebral consumption of oxygen does not follow the decrease in hemoglobin and cerebral metabolic rate of oxygen consumption, thus demonstrating better stability to changing hemoglobin content. The low cerebral metabolic rate of oxygen consumption is due to a decrease in arterio-jugular oxygen content difference in anemia, while the cerebral extraction of oxygen does not follow the trend of the arterio-jugular oxygen content difference.

Question: Cerebral blood flow and oxygen consumption in acute brain injury with acute anemia: an alternative for the cerebral metabolic rate of oxygen consumption?

In acute brain trauma with acute anemia, calculated arterio-jugular oxygen content difference and cerebral metabolic rate of oxygen consumption tend to be progressively lower, depending on the extent of anemia, which is in disagreement with coma scores. These changes in hemoglobin tend to have an inverse influence on cerebral consumption of oxygen, which, therefore, constitutes an alternative and independent measure of cerebral oxygen and independent measure of cerebral oxygen consumption under these limiting circumstances.

Answer the question based on the following context: To examine the impact of pulse oximetry on the use of arterial blood gas and other laboratory determinations and to examine predictors of the use of arterial blood gas measurements. Before (preoximetry)/after (postoximetry) study. Thirty-bed multidisciplinary critical care unit. Consecutive admissions of 300 patients (150 before and 150 after oximetry). For each patient examined, the number of arterial blood gas determinations, serum electrolyte levels, complete blood chemistries, arterial lactate levels, and creatinine samples were recorded for the initial 9 days of the stay in the critical care unit. These data were stratified by nursing shift (day vs night) and by the source of the admission (medical vs surgical). Other information collected included demographic variables, the severity of illness, the length of stay in the critical care unit, and various ventilatory parameters. Introducing pulse oximetry was associated with a marginal (10.3 percent; p<0.025) reduction in the use of arterial blood gas determinations. This decrease was accounted for by changes occurring on the night shift and in the surgical patient. These findings were also observed for serum electrolyte determinations. No significant differences in the use of arterial blood gas measurements were found for medical patients. No significant differences were found in the use of arterial lactate levels, complete blood chemistries, or creatinine determinations. Significant predictors of arterial blood gas determinations included the number of days intubated, the number of ventilator orders, the number of days on an inspired oxygen content (FIO2) greater than 50 percent, and the acute physiology and chronic health evaluation II (APACHE II) score.

Question: Does implementing pulse oximetry in a critical care unit result in substantial arterial blood gas savings?

The implementation of pulse oximetry in this manner gives an idea how effective the technology will be in reducing the use of arterial blood gas determinations without guidelines for the use of pulse oximetry. As only a marginal decrease was observed in the total population of medical and surgical patients, and only on the night shift, formal and standardized guidelines for the most efficient use of pulse oximetry should be considered. If these were considered, pulse oximetry may indeed make a significant contribution to improving the efficiency of care services.

Answer the question based on the following context: To evaluate drug management of acute cocaine toxicity in a new animal model. The study null hypothesis was that no drug would affect outcome compared with a placebo control.MODEL: Chronically instrumented, conscious, unrestrained rats subjected to an LD50 dose (1.4 mg/100 g body wt) of IV cocaine. Rapid injection of IV cocaine by IV vascular access port followed by injection of therapeutic study drugs. Outcome (survival vs death) with drug treatment was compared with a placebo group. Normal saline placebo (0.2 mL/100 g), diazepam (0.5 mg/100 g), chlorpromazine (0.2 mg/100 g), propranolol (1.0 mg/100 g), labetalol (3.0 mg/100 g), or verapamil (0.1 mg/100 g) was given. There were ten rats in each treatment group. Allocation to treatment groups was nonrandomized. Fisher's exact test. IV injection of cocaine was followed by tonic-clonic seizure activity in all treatment groups. No study drug significantly improved survival compared with the placebo group. However, no animal treated with propranolol survived (P less than .05 vs saline control), and only one of ten animals treated with labetalol survived (P = .14 vs placebo group).

Question: Pharmacologic interventions after an LD50 cocaine insult in a chronically instrumented rat model: are beta-blockers contraindicated?

In this conscious animal model subjected to an LD50 IV cocaine insult, chlorpromazine and diazepam, previously shown to be of value in other animal models, had no effect on survival. Verapamil also did not affect outcome. Outcome was adversely affected by treatment with beta-blocking agents.

Answer the question based on the following context: To compare recent trends in smoking initiation by adolescents with trends in inflation-adjusted cigarette pricing and tobacco marketing expenditures. We examined smoking initiation trends in demographic subgroups of adolescents aged 14-17 years during the decade 1979-1989. Data on cigarette pricing and tobacco marketing expenditures were adjusted for inflation and plotted over this same period. Large population surveys, United States. 140,975 ever-smokers aged 17-38 when surveyed in 1992 or 1993, who reported on age of smoking initiation during the decade 1979-1989. Initiation rate was calculated as the number in an age group who reported starting to smoke regularly in a year, divided by the number of never-smokers at the start of the year. Trends were evaluated by linear and quadratic models. From 1979 to 1984, adolescent initiation rates decreased, but increased thereafter, particularly among males, whites, and those who, as adults, reported never having graduated from high school. Cigarette price increased throughout the decade as did tobacco marketing expenditures, especially for coupons, value-added items, and promotional allowances.

Question: Trends in adolescent smoking initiation in the United States: is tobacco marketing an influence?

Availability of cheaper cigarettes is not likely to be a cause of increased smoking initiation by adolescents. Although other influences cannot be ruled out, we suspect that the expanded tobacco marketing budget, with its increased emphasis on tactics that may be particularly pertinent to young people, affected adolescent initiation rates.

Answer the question based on the following context: The purpose of this study was to use an 11-state, population-based hospital discharge database to assess the charges for care of patients undergoing cholecystectomy at both medical school affiliated hospitals (MSAHs) and private hospitals (nonMSAHs). It was our hypothesis that MSAHs could indeed provide efficient, competitively priced patient care. Data were obtained from the Healthcare Cost Utilization Project of the Agency for Health Care and Policy Research. The database tracks information on all hospitalized patients from 11 states for the years 1988-1992. Represented in the study were 849 nonMSAHs (82%) and 191 MSAHs (18%). During the 5 years of the study, 351,201 patients underwent cholecystectomy. The mean charges and the lengths of stay were similar in the two diagnosis related groups (DRGs) studied (197,198). The analysis demonstrated that during this same period, MSAHs led in both the adoption of laparoscopic cholecystectomy and decreased use of intraoperative cholangiography.

Question: Can medical school-affiliated hospitals compete with private hospitals in the age of managed care?

Others have reported that MSAHs cannot compete with nonMSAHs in providing competitively priced care. The present study shows that for cholecystectomy, charges and length of hospital stay are comparable in MSAHs and nonMSAHs. This study supports the hypothesis that the leadership provided at United States medical schools may also extend to the area of cost-efficient care and hints at further areas of improvement.

Answer the question based on the following context: Pulmonary contusion (PC) is a common sequelae of blunt trauma in adults and children; previous reports suggest that children have more favorable outcomes because of differences in mechanisms of injury, associated injury, and physiologic response. Our objective was to determine whether children who sustain PC have different outcomes compared with similarly injured adults. Our Level I Trauma Registry was reviewed for a 4-year period and identified 251 consecutive patients who sustained PC. Their charts were reviewed retrospectively for demographics, injury mechanism, injury severity scores, associated injuries, and outcomes (measured by the need for intubation, ventilation days, pneumonia, acute respiratory distress syndrome, and death). Data are expressed as the mean +/- SEM. The Student's t-test was used to compare the groups. A p value less than 0.05 was considered significant. Of the study patients, 41 (16%) were children (ages 2-16, mean 10 years) and 210 (84%) were adults (ages 17-80, mean 34 years). The most common injury mechanisms in children were motor vehicle accidents (56%) and auto-pedestrian accidents (39%), but in adults, motor vehicle accidents (80%, p = 0.02) predominated. Injury severity score was not significantly different between groups (children, 26 +/- 2 and adults 25 +/- 1). Similarly, the incidence of associated injuries was not different between children and adults: head 78% versus 62%, abdomen 59% versus 43%, and skeletal fractures 41% versus 29%, respectively. Neither need for intubation, ventilator days, pneumonia, acute respiratory distress syndrome, or death differed significantly between groups.

Question: Pulmonary contusion: are children different?

Although children and adults differ in regard to injury mechanism, their overall injury severity, associated injuries, and outcomes are quite similar. Thus, contrary to previous reports, children do not have a more favorable outcome after PC.

Answer the question based on the following context: Unlike vein bypasses, the role of duplex surveillance of infrainguinal prosthetic bypass grafts is controversial. The purpose of this study was to evaluate the adequacy of color duplex surveillance in identifying failing infrainguinal polytetrafluoroethylene (PTFE) bypass grafts and to assess its value in predicting continued bypass patency. The surveillance data of primarily patent PTFE bypass grafts were compared with those of revised/occluded PTFE grafts. Ninety-five patients underwent 102 infrainguinal PTFE bypass grafts from January 1991 to December 1996 and were enrolled in a duplex surveillance program at 1 month postoperatively, every 3 months in the first year, every 6 months in the second year, and yearly thereafter. Seventy grafts remained primarily patent, 5 were revised and 27 occluded. There was no significant difference in the mean age, gender, indication for surgery, type of original procedure, or duration of follow-up between both groups. Four hundred and seven duplex surveillance data were available for analysis. Focal increase in peak systolic velocity (PSV) 3 x the adjacent segment or low flow manifested by PSV<45 cm/sec were considered abnormal. In the primarily patent group, 5 bypasses had abnormal duplex surveillance and were found to have no abnormality on angiogram and remained patent during the study period. In the revised/occluded group, duplex surveillance was abnormal in 8 bypasses. Twenty-four bypasses occluded without any predicting abnormalities on their last duplex examination, which was performed within 3 months from the occlusion in the majority of the patients. In the 27 occluded bypasses, no intervention was necessary following the occlusion in 7 grafts because of mild or no symptoms. Two patients were treated with a primary amputation and 2 had new bypasses. In 16 occluded grafts, salvage of the PTFE bypass was attempted. Ten of these grafts were patent at the end of the follow-up. The sensitivity of duplex surveillance was 25% with a positive predictive value of 61.5%.

Question: Is color duplex surveillance of infrainguinal polytetrafluoroethylene grafts worthwhile?

Duplex surveillance of infrainguinal PTFE bypass grafts has a low yield and is inadequate at predicting continued bypass patency.

Answer the question based on the following context: The results of renal transplantation in obese recipients have been controversial, with some reports finding increased morbidity prohibitive and others finding increased morbidity acceptable. We attempted to determine whether obese patients in extreme excess of their ideal body weight should undergo transplantation. The study population included 127 obese (body mass index>30 kg/m2) patients who were compared with a matched nonobese control group (body mass index<27 kg/m2) of 127 recipients with similar demographics. There were no significant differences between the groups according to donor source, recipient race or sex, retransplants, transplant percent reactive antibodies, cause of renal failure, or hypertension. However, significantly more obese patients had a pretransplant history of angina (11.2% vs. 3.2%, P=0.02) or a previous myocardial infarction (5.6% vs. 0.8%, P=0.04). The mean follow-up was 58.9+/-40 (range 3-170) months. Nonobese patients enjoyed a significantly (P=0.0002) greater patient survival (89% vs. 67%) at 5 years and suffered only about half the number of deaths (25 vs. 46) during the period of observation. Cardiac disease was the leading cause of death (39.1%) in the obese group. Patient death had a major impact on graft survival because there were no differences between the groups when death with graft function was censored from the analysis. There were no significant differences between the groups in delayed graft function, acute rejection, chronic rejection, length of hospital stay, operative blood loss, or mean serum creatinine up to 5 years. However, obese patients experienced significantly (P=0.0001) more complications per patient (3.3 vs. 2.2) and a greater incidence (P=0.0003) of posttransplant diabetes (12% vs. 2%). Similar cyclosporine blood levels were observed in obese recipients even though they were receiving 0.75-2 mg/kg/day less cyclosporine than the nonobese recipients.

Question: Should obese patients lose weight before receiving a kidney transplant?

Outcome differences in obese renal transplant patients were primarily due to a higher mortality resulting from cardiac events. Obesity seems to have little effect on immunologic events, long-term graft function, or cyclosporine delivery. Aggressive pretransplant screening for ischemic heart disease is essential to identify an especially high-risk subgroup of obese patients. Although it would seem prudent to recommend weight reduction<30 kg/m2 to all patients before transplant, these data suggest that obese patients with a history of cardiac disease should not be transplanted until weight reduction has been accomplished.

Answer the question based on the following context: Our goal was to determine whether spleen or muscle can be used as a qualitative standard of reference for diagnosing fatty infiltration of liver on contrast-enhanced CT. Qualitative visual comparisons and quantitative region-of-interest measurements of liver, spleen, and muscle were made on scans of 96 patients who underwent dynamic CT before and after injection of intravenous contrast material. As the standard of reference, the portion of liver assessed was considered fatty if its attenuation measured less than spleen on noncontrast CT. In 16 (17%) scans, the portion of liver assessed was fatty on noncontrast CT. After contrast material administration, the attenuation of that portion of liver measured less than splenic attenuation in 93 (97%) of 96 cases (including all 16 fatty livers). Only four (25%) fatty livers, and no nonfatty livers, were visually judged to be less attenuating than muscle after contrast material; these four were the most fatty shown on noncontrast CT. Comparing hepatic and splenic attenuation on postcontrast CT resulted in a specificity of 30% and a positive predictive value of 20%; comparing hepatic and muscle attenuation on postcontrast CT yielded corresponding values of 100 and 100% but a sensitivity of 25%.

Question: Qualitative assessment of liver for fatty infiltration on contrast-enhanced CT: is muscle a better standard of reference than spleen?

For the visual assessment of fatty liver, spleen is not an accurate reference standard on contrast-enhanced CT. However, fatty liver can be diagnosed on contrast-enhanced CT if liver appears less attenuating than muscle-a situation that occurs only if fatty infiltration is pronounced.

Answer the question based on the following context: Nothing is yet known of possible endocrine effects of transurethral microwave thermotherapy (TUMT) or of possible influence of endocrine status on the result of thermotherapy. Serum levels of testosterone (T), SHBG, estradiol, LH, and PSH were measured in 48 men with BPH before and 2-3 months after TUMT (Prostatron, Prostasoft 2.0; Technomed International, Lyon, France). Assessment of results was based on the patients' own estimations. The treatment did not alter hormone levels. Patients who reported response after 12 months (n = 21) had significantly lower outset levels of calculated free testosterone (fT) than in the nonresponders (n = 27). In the patients aged<70 years (n = 13), both the fT and T values were lower than in the nonresponders (n = 15). There was no age difference between responders and nonresponders.

Question: Transurethral microwave thermotherapy in symptomatic benign prostatic hyperplasia: a possible association between androgen status and treatment result?

TUMT did not influence hormone levels. These observations suggest that androgen status may influence the final result of treatment.

Answer the question based on the following context: To determine whether zinc, which blocks apoptosis in many systems, including in leukemic cells and possibly in retinal dystrophies, can prevent the unwanted loss of anterior stromal keratocytes after superficial keratectomy. After mechanical central corneal epithelial debridement, the left eyes of nine New Zealand white rabbits were treated with 25 mM zinc chloride (ZnCl2) in Earle's salts minimal essential medium (MEM) either every 30 min (n = 3), every 2 h (n = 3), or every 4 h (n = 3). The left eyes of nine additional animals, divided into three equal groups, were deepithelialized, and each received pure culture medium at one of the same three frequencies. One eye of each of another six rabbits was deepithelialized but received no drops. After 24 h, all 24 animals were sacrificed and the globes were enucleated. The corneas were processed and sections were stained with hematoxylin and eosin. The cell count of MEM-treated corneas exceeded that of untreated corneas (p = 0.03, analysis of variance [ANOVA]), but there was no difference among eyes that received the different frequencies of MEM application (p = 0.36, ANOVA). Cell counts increased with frequency of zinc application, but the differences were not statistically significant (p = 0.09, ANOVA). Only in the group receiving the most frequent zinc applications were superficial keratocytes retained. This group also possessed a greater number of stromal keratocytes than untreated controls and MEM-treated corneas (p = 0.01).

Question: Can zinc prevent apoptosis of anterior keratocytes after superficial keratectomy?

At a significantly high dosage, zinc can prevent loss of superficial keratocytes to a greater extent than culture medium alone can. Moreover, zinc has the advantage of preserving the most anterior layer of keratocytes. Retention of these cells may prevent the reactive overproliferation that constitutes haze after photorefractive surgery.

Answer the question based on the following context: Hypothyroidism often remains undetected because of the difficulty associating symptoms with disease. To determine the relation between symptoms and biochemical disease, we assessed symptoms and serum thyroid function tests, concurrently, for patients with and without hypothyroidism. Cross-sectional study.SETTING/ Seventy-six newly diagnosed case patients with overt hypothyroidism and 147 matched control patients identified through outpatient laboratories in Michigan and Colorado. Patient symptoms were assessed by questionnaire. Case patients reported a higher proportion of hypothyroid symptoms than did control patients (30.2% vs 16.5%, p<.0001). Univariate analysis identified three significant predictors of an elevated level of thyroid-stimulating hormone (TSH) (p<.05), and 13 symptoms which, when they had changed in the past year, were reported more often by case patients with hypothyroidism than by control patients (p<.005). Individuals reporting changes in 7 or more symptoms were significantly more likely to have hypothyroidism (likelihood ratio [LR] = 8.7, 95% confidence interval [CI]3.8, 20.2); those reporting changes in 2 or fewer symptoms were less likely to have hypothyroidism (LR = 0.5, 95% CI 0.4, 0.7).

Question: Do traditional symptoms of hypothyroidism correlate with biochemical disease?

In this sample, the number of hypothyroid symptoms reported was directly related to the level of TSH. The association was stronger when more symptoms were reported. Symptoms that had changed in the past year were more powerful than symptoms reported present at the time of testing. This suggests that traditional symptoms are valuable when deciding which patients to test for hypothyroidism.

Answer the question based on the following context: The objective of this study was to analyse and quantify the effect of patients gender on Primary Care clinical histories (PCCH) of the over-14 population. An observational cross-sectional study. Primary Health Care. A total sample of 1,449 PCCH from six Health Districts in Catalonia were evaluated. These districts had a professional staff of 55 doctors, 55 nurses and 30 clerical auxiliaries. Internal audit of the random sample of 1,449 PCCH was carried out to see that they satisfied the following criteria: PCCH belonging to population registered in the District, born before 1980 and who had attended for consultation at least once in the previous five years (between 1990 and 1994). To measure the quality of PCCHs, a questionnaire with 23 structured indicators in three sections was used to collect information on recording of sociodemographic data, administrative details and data concerning health. Higher recording of all items occurred in female users, older users, less time elapsed since previous consultation, and when the town where the PC Centre was located had<1000 inhabitants.

Question: Does patient's gender affect the quality of clinical histories in primary care?

The analysis of the results suggests the need to improve the effectiveness of the PCCH as an instrument to achieve equality in individual care.

Answer the question based on the following context: The objective of this study was to identify existing problems in the coordination between the different levels of the pediatric care system and suggest possible solutions. A poll of 66% of the health center pediatricians (HCP) of the greater metropolitan area of Valencia (city + 30 km) on the problems in the coordination between HCP and hospital pediatricians (HP), possible solutions and the number of patients per HCP per day, including the average and range, was performed. Answers were received from 54% of the HCP (n = 51), which represented 81% of the sample. Problems were identified in coordination (100%), institutional organization (98%), communication (96%), access to reports from outpatient clinics (84%), lack of time and mobility of the HCP (33%), and in the structure of the emergency service for primary child care (ESPCC; 4%). The suggested solutions were; None (6%), global institutional organization (94%) by creating a hierarchy in the HP and HCP, meetings and protocols by consensus, rotation of HP, HCP and pediatric residents between health centers and hospitals, institutionalized intercommunication, allotting time and work mobility to HCP, limiting patients per day and planning ESPCC in hospitals. The average number of patients per day was 32 +/- 8 patients/day (pd), range: 5-100 pd, with 92% of the HCP seeing>20 pd, 63%>30 pd, 17%>40 pd and 2%>50 pd. At>6 km from the city there is no coordination and the number of patients/day is greater (p<0.02).

Question: Is the pediatric service coordinated?

There is no institutionalized coordination between HP and NCP. The greater the distance from the city, the greater the overload and the lower the coordination. There is a lack of institutional organization.

Answer the question based on the following context: The authors compare the risk of bacteraemia in open and laparoscopic appendectomy in a prospective randomized study. 35 patients with a presumptive diagnosis of acute appendicitis were randomized to have conventional open or laparoscopic surgical procedures. Before randomization, patients signed a consent form to participate in the study. Patients who were converted from laparoscopic to open appendectomy (3 cases), HIV+, allergic to Augmentin or who had contraindications to laparoscopic surgery were excluded from the study. A total of 32 patients were randomized: 17 to open (group I) and 15 to laparoscopic surgery (group II). There were no significant differences with regard to age, ASA score, symptoms or macroscopic aspect of the appendix. Two patients had a normal appendix, 12 had acute appendicitis, 14 gangrenous appendicitis and 4 ruptured or abscessed appendicitis. All patients received preoperative antibiotic prophylaxis (Augmentin) after blood cultures (H1) were drawn. Five other blood cultures were performed in standard medium and medium neutralizing Augmentin: at the time of opening the peritoneum (H2), after appendectomy (H3), after closure of the abdomen (H4), and at 6 (H5) and 12 hours (H6) after the operation. Bacterial cultures from the appendix site were performed before (P1) and after (P2) appendectomy. The operative mortality rate after conventional or laparoscopic appendectomy was nil. The incidence of post-operative morbidity was 4 cases in group I and 2 cases in group II. No positive bacterial culture was obtained in 17 patients. The distribution of these patients was similar in groups I and II. Samples P1 and P2 were positive in 5 cases. Nine of 27 cases with negative P1 became positive in P2 (33%). There was no significant difference between the two groups with regard to the appearance of the appendix. Only two patients had positive blood cultures at H1. One of them had blood cultures at H3, H4 positive for a second germ.

Question: Does laparoscopy increase the bacteriological risk of appendectomy?

A low risk of bacteraemia exists for both open and laparoscopic appendectomy. This risk did not appear to increase for laparoscopy. Conventional and laparoscopic surgical procedures led to positive peritoneal bacterial cultures after appendectomy in 33% of cases.

Answer the question based on the following context: EMG examination at tender points affects myofascial pain symptoms related to cervical nerve root irritation. Consecutive patients with neck and arm pain had physical examinations immediately before and after having EMGs of bilateral C3-C8 myotomes. Patients were randomly chosen for EMG either at the most tender point along the palpated myofascial band or at a nonselected site. The myotomal presence of>or = 30% incidence of normal duration and amplitude, and polyphasic motor unit potentials confirm the diagnosis of cervical nerve root irritation. 52% returned patient questionnaires 2 weeks post EMG examination. Group I (82/122 patients [67.2%]), averaged pain relief of 51.8 +/- 21.9%, a mean of 10.2 +/- 8 days; 14% had>or = 75% relief. The number of days of pain relief correlated positively with the percentage of pain relief (p<0.005), but negatively with the number of nerve roots involved on EMG (p<0.05). Group 2 (23/42 patients [54.8%]), averaged relief of 39.0 +/- 18.7%, lasting 8.8 +/- 11.2 days. None had>or = 75% pain relief. Both groups' duration of pain symptoms affected onset of relief. Evidence of bilateral multiple-level cervical nerve root irritation, especially noted at bilateral C6 and C7 levels.

Question: Does EMG (dry needling) reduce myofascial pain symptoms due to cervical nerve root irritation?

EMG at tender points on myofascial bands tends to improve symptoms. Needling these points elicits motor endplate activity and twitches, and induces more relief than when needling random points.

Answer the question based on the following context: The objective of this study was to test the hypothesis that long-term occupational exposure to organic solvents may effect the levels and turnover of dopamine in man. A study was performed on 17 patients with neuropsychiatric symptoms due to occupational solvent exposure, and 11 healthy non-exposed male volunteers (controls). Positron emission tomography (PET) was used to assess striatal dopaminergic function, using L-[11C]DOPA, [11C]nomifensine and [11C]raclopride as tracers. The rate of dopamine synthesis was significantly increased among subjects with occupational exposure to organic solvents compared with non-exposed controls. After controlling for the difference in age between exposed and controls, the effect of solvent exposure became less apparent and was reduced from +32% (P = 0.009) to +25% (P = 0.07). There were no differences with regard to the binding of [11C]nomifensine. Patients with and without the diagnosis of toxic encephalopathy did not differ with regard to their putaminal uptake of L-[11C]DOPA, [11C]nomifensine and [11C]raclopride.

Question: Do organic solvents induce changes in the dopaminergic system?

The data support the hypothesis that long-term exposure to organic solvents may increase the rate of dopamine synthesis in the brain without affecting the number of presynaptic terminals or postsynaptic dopamine receptors.